Nsg.notes 1900-0700hrs

A case of s/p LSCS ,Hystrectomy,oopherectomy,PMH of haemoglobinuria ,intubated and ventillated for further management and for blood transfusion as crit remains low.

Events:one unit blood was on progress from previous shift and one more unit red cells and one unit platelets transfused and rechecked crit,report 26 from previous 25.planned to do CT abdomen and pelvis in view of low crit to check any further bleeding or haematoma formation.so went for CAT scan at 0300hrs and CT abdomen and pelvis done,verbal report from ICU team :haematoma remains same ,no further bleeding noted.requested for 4 more unit blood cross match and order to transfuse two more.

Neuro:sedated,responds to pain and call.moves head sideways and coughs.

Resp:intubated and ventillated,AC mode,RR 20/PEEP 5/FIO2 30%/TV 550ml/suctioned moderate amount secretions.sats remains > 95%.blood gas done early shift and AM ,pls see carevue for reports.

CVS:HR 70-80/min,NSR,no ectopics noted.follow crit and blood transfusion accordingly.am smples sent.pls see carevue for more details.

GU/GI:NPO,[**Hospital1 **] sump OGT in place.abdomen soft and distended,bowel sounds hypo.dressing on lower abd.looks clean,no oozing noted.no BM this shift.on foley cath,urine output adequate,urine turned to light green colour from yellow,may be due to propofol infusion.

IV access:2 PIV'S on Lt.hand and one on Rt.hand,patent dressing intact,no swelling or pain noted.one PIV from Lt.hand found not running well ,so removed and new PIV inserted on same hand.A line on Rt.radial,[patent,good blood flow,BP monitoring.

Social.visited by husband and updated with MD,full code.

Plan:monitor crit and blood transfusion if needed.ICU care.titrate sedation if possible.


[**2128-5-16**] 12:51 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 76599**]
 Reason: eval infiltrate
 Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;FEV
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


77 year old man , intubated after stroke


REASON FOR THIS EXAMINATION:


eval infiltrate
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Intubated.

 Single portable chest radiograph demonstrates interval removal of the
 nasogastric tube when compared to [**2128-5-13**].  The remaining support lines
 remain in place and are unchanged.  Tracheostomy tube is again noted.  There
 is mild blunting of the left costophrenic angle, representing a small pleural
 effusion.  Bibasilar atelectasis persists and is slightly improved when
 compared to the previous study.


IMPRESSION:


Interval removal of nasogastric tube.  Otherwise, unchanged appearance of the
 chest.


AT 2045, PT WENT INTO SLOW VTACH, RATE 150.  LIDOCAINE AND VERSED GIVEN, FOR CARDIOVERSION, BUT RHYTHM SUCCESSFULLY TREATED WITH RAP AT 200.  SBP DROPPED TO 70 VERY TRANSIENTLY, RESPONDED TO TRENDELENBERG, NO NEO NEEDED.  RECENT K WAS 3.6, KCL BOLUS GIVEN.  PO2 AT [**2167**] WAS 59, WAS TACHYPNEIC TO 38 AND SPO2 WAS 90% ON 5L NC AND 70% FACE TENT WHEN DRAWN.  REPORTED TO DR. [**Last Name (STitle) 804**], CXR ORDERED.  SPO2 IS NOW 94%.  PT IS ASLEEP AFTER EARRLIER SEDATION.


[**2145-6-15**] 5:10 PM
 RENAL U.S. PORT                                                 Clip # [**Clip Number (Radiology) 66213**]
 Reason: WORSENING CONDITION PLEASE REPEAT RENAL US
 Admitting Diagnosis: LEUKEMIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


69 year old woman with new renal failure, pending HD line placement and HD
  initiation.  Has recent U/S but not valid given clinical change


REASON FOR THIS EXAMINATION:


Please repeat Renal U/S
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc TUE [**2145-6-15**] 7:23 PM
  No evidence of obstruction as cause for acute renal failure.  Possible trace
  perisplenic fluid seen.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


69-year-old female with new renal failure, and pending hemodialysis
 line placement for hemodialysis administration.  Here to assess for cause for
 acute renal failure.


COMPARISON:


Abdominal ultrasound studies from [**2145-6-15**], [**2145-5-31**], as well as CT
 abdomen/pelvis, most recently on [**2145-2-16**].

 RENAL ULTRASOUND (PORTABLE):  The kidneys measure 10.0 cm on the right and
 10.8 cm on the left.  The study is slightly limited due to difficulty with
 son[**Name (NI) 15**] penetration, however, no evidence of hydronephrosis, stones, or
 renal mass is seen.  There may be trace perisplenic fluid.  The urinary
 bladder is only mildly distended but appears unremarkable.


IMPRESSION:


No evidence of obstruction seen as cause for acute renal failure.


Sinus tachycardia.  Non-specific ST-T wave changes.  There is an RSR' pattern
in lead V2 which is probably normal.  No previous tracing available for
comparison.


25 yr old male with no significant PMH noticed new onset of head achae
   during weight lifting session about a month ago. At rest no symptoms.
   Presented to OSH with increased HA w/ N/V  on [**11-7**] Ct head revealed lt
   cerebellar mass with effacement of 4
Th ventricle. Admitted to [**Hospital1 1**]
   and he had a third ventriculostomy, kept in pacu overnight transferred
   to neuro floor and was neurologically stable, and the pt was discharged
   home on [**11-15**]. Readmitted on [**11-19**] for elective posterior fossa
   craniectomy tumor resection. Transferred to SICU for neuro checks post
   op
   .H/O pain control (acute pain, chronic pain)
   Assessment:
   c/o of pain [**2130-5-1**] and neck stiffness feels muscular.
   Action:
   Oxycodone 5mgs with valium 5 mgs po
   Tylenol 650 mgs rtc.
   Response:
   Pain control improved and needs  medication  less frequently
   Plan:
   Continue with present pain regime reassess frequently.
   .H/O [**Last Name **] Problem - [**Name (NI) 20**] Description In Comments
   Assessment:
    pod# 2 s/p  cerebellar tumour  resection [**11-19**],
   Action:
   Q1 changed q2 neuro obs  per neuro [**Doctor First Name **].
   sbp changed to 100-150
    750 mls fluid restriction for low sodiums
   Mannitol 25 gms q6 check osmo and sodium levels prioir to admission.
   Response:
   Stable neuro obs  neck swelling still present
   Both arms with equal strength and dexterity
   Plan:
   Continue neuro obs q2
   Continue fluid restriction at 750 mls/24 hr continue salt tabs
   Continue manitol until sodium levels improve leave foley in place
   meantime
   Can transfer to neuro stepdown unit.


[**2188-5-4**] 5:04 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 18781**]
 Reason: F/u CHF.
 Admitting Diagnosis: BILATERAL PULMONARY NODULES/SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


67yo F s/p VATS.


REASON FOR THIS EXAMINATION:


F/u CHF.
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST X-RAY, [**2188-5-4**]


COMPARISON:


[**2188-5-3**].


INDICATION:


CHF.

 A feeding tube remains in place with tip directed cephalad in the stomach.
 The heart is enlarged.  There has been interval improvement in degree of
 pulmonary edema.  Bilateral pleural effusions, right greater than left are
 unchanged as well as an area of post-operative atelectasis adjacent to
 surgical chain sutures in the periphery of the right lower lobe.


IMPRESSION:


Improving congestive heart failure.


Neonatology Attending
Error - Please disregard this note, which was entered on the wrong patient.


[**2169-9-16**] 4:18 PM
 T-SPINE; L-SPINE (AP & LAT)                                     Clip # [**Clip Number (Radiology) 74127**]
 Reason: s/p fall with ecchymosis over back eval for fracture
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


38 year old man with


REASON FOR THIS EXAMINATION:


s/p fall with ecchymosis over back eval for fracture
 ______________________________________________________________________________


FINAL REPORT


CLINICAL HISTORY:


Fell on back.  Ecchymosis over back.  Evaluate for
 fracture.

 There is a wedge fracture of the body of T12.  No other fractures of the
 thoracic spine are seen.

 LUMBAR SPINE:

 Contrast is seen in both kidneys and ureters which appear normal.  Some
 degenerative changes are present within the lumbar spine particularly at L1-2
 but no fracture is seen.


IMPRESSION:


Wedge fracture of body of T12.


Admission Date:  [**2169-3-16**]              Discharge Date:   [**2169-3-22**]

Date of Birth:  [**2088-4-18**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall

Major Surgical or Invasive


Procedure:


None


History of Present Illness:
Pt is an 80m who was transferred to [**Hospital1 18**] from OSH with frontal
contusions and interventricular hemorrhage after an unwitnessed
fall. He was originally taken to OSH after his downstairs
neighbor heard the fall and called 911. He has a long history of
frequent falls and ETOH abuse. He currently denies any pain,
weakness in extremities, speech difficulty or visual
disturbances.

Past Medical


History:


ETOH abuse, HTN, BPH, Aortic valve replacement, CABG,
Protstate Cancer


Social


History:


Lives Alone, ETOH abuse

Family


History:


NC

Physical


Exam:


BP: 137/55  HR: 66  R   16  O2Sats 98
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA 3-2mm     EOMs FULL
Neck: C Collar in place, no tenderness to palpation

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only
Recall: Unable to recall [**2-2**] objects at 5 minutes.
Language: Speech fluent No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. Right pronator
drift.

Sensation: Intact to light touch bilaterally.

PHYSICAL EXAM UPON DISCHARGE:
awake, alert to self only
PERRL, EOMI
face symmetric, tongue midline
ecchymosis on right temple
no pronator drift
MAE's with good strengths
following commands


Pertinent Results:
CT Head [**3-16**]
1. Slight interval increase in size of small hemorrhagic
contusion in the
left lateral inferior frontal lobe.
2. Stable hemorrhagic foci in the subarachnoid right frontal
lobe and
subependymal right lateral ventricle.
3. Interval increase in amount of dependently layering
ventricular blood,
source unclear. [**Name2 (NI) **] change in ventricle size.Correlate clinically
and for coagulopathy and consider close followup.

Hand x-ray [**3-17**] - : There are two osseous fragments adjacent to
the
volar and ulnar base of the first distal phalanx. One may
represent a
sesamoid, however, the other likely represents an
age-indeterminate fracture.  There are moderate degenerative
changes of the IP joint with osteophyte formation as well as
moderate degenerative changes of the triscaphe joint.
Degenerative changes at the first CMC are milder in extent.
Vascular
calcifications are diffuse. Soft tissue swelling about the thumb
is moderate.

[**3-22**] HEAD CT and C SPINE CT- preliminary read no acute changes.
interval resolution of SAH.


Brief Hospital Course:
Patient presented to the ER s/p fall at home as a trasnfer from
an OSH. Upon arrival and assessment he was admitted to the ICU
for further observation and management. Repeat Head CT showed
some increase in the left lateral ventricle IVH however his
clinical exam was improving. He continued in a hard cervical
collar into [**3-17**] and it was decided that he would remain in the
collar for two weeks and then return with imaging to assess
stability.

On the afternoon of 4.15 he was deemed stable for transfer to
the floor for disposition planning. PT and OT consults were
ordered to determine the best disposition for him. There was no
bed available on the floor and the patient stayed another night
in the trauma ICU.  A hand x-ray demonstrated right thumb
osseous fx at IP/volar aspect and according to trauma no
splinting or f/u is needed.

On [**3-18**], transfer orders rewritten for transfer to the floor.
The patient keppra ws increased to 750 [**Hospital1 **].The trauma ICU team
reviewed his right hand [**Last Name (un) **] xray which was consistent with
osseus frags at IP/volar aspect and reccomenede there is no need
for splinting of this fracture

On [**3-20**], The patient exam was stable. The patient was oriented
to self and hospital not date, given choices. He continues to
wear a [**Location (un) **] J cervical collar. He was able to moves all
extremities well with good strength. He denied right thumb
discomfort
The patient INR was 1.4.  Liver Function Tests were ordered
which showed AP/LDH were slightly elevated. A Social Work
Consult was ordered as the patient lives alone and the daughter
is worried that the patient suffers from self netglect. The
daughter does not feel that he is safe to go home as he is
disoriented and does not eat. The patient serum potassium was
3.6 and repleated serum magnesium was 1.8 both were repleated.
He was evaluated by speech who recommended soft/reg thin
liquids.  PT/OT recommened acute rehab.

Now DOD, patient is afebrile, VSS, and currently neurologically
stable. He was given an Aspen collar which he should remain
wearing at all times until follow up.  He is tolerating a
soft/thin liquid diet.  He is set for discharge to rehab and
will f/o with Dr. [**Last Name (STitle) **] in 2 weeks.


Medications on Admission:
oxybutin, lopressor

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
parafalcine SDH
IVH
Neck pain


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????       You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
??????       Continue to wear your cervical collar at all times. You
may remove it only to change the collar following a shower
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 2 weeks.
??????You will need Flexion/Extension X-rays prior to your
appointment. This can be scheduled when you call to make your
office visit appointment.



Completed by:[**2169-3-22**]


micu npn 1900-0700
Please see carevue flowsheet for all objective data

Neuro- Patient lethargic for the most part, sleeping when left alone. Oriented x2-3. At times difficult to elicit a response in answer to question.. she is also somewhat difficult to understand.

CV- HR 80's nsr w/no ectopy. She is on mult anti-htn meds, taking most at [**2178**] last eve, she was also begun on isordil yesterday. She continues to be hypertensive at times, qid hydralizine has been helping w/this as well in addition to po meds.

[**Name (NI) **] Pt continues to exhibit son[**Name (NI) **] breathing pattern. After aggressive mouth care last eve, she began to have some secretions that she was unable to expectorate on her own. She has a weak gag and [**Last Name (LF) **], [**First Name3 (LF) **] [**First Name3 (LF) **] up secretions if able to get yankaur to the back of her throat. She remains on 3l nasal cannula. Some i/e wheezing noted.

gi/gu- remains npo. feeding tube in for meds. ?to have a video swallow at some point. ?plan for nutrition. Not on feeds or any maint ivf's. No stool noted this shift. uop adequate. ?order to d/c foley this am.

social- pt's brother in from ny to visit. Is in the area today as well..

Patient remains c/o to floor.

**Of note, pt has a loose front upper tooth


NPN 1900-0700 cont'd


Parenting: [** **] in for 2200 cares. Participated in cares
and weighing of infant. Mom did temp and diaper and lifted
[**Known lastname 1236**] from scale to bed with help from this RN and RRT. [**Name (NI) 29**]
also held infant briefly while infant off Oscillator, with
aid and support of RRT. Footprints/photo done by this RN and
given to [**Name (NI) 4**], [**Name (NI) 4**] very excited to take photo home to
4 year-old son. [**Name (NI) 59**] return tomorrow evening. P: COntinue to
update, educate and support NICU family.

FEN: Wt=1095gm, +5g. PT remains NPO s/p medical NEC. TF
remain 140cc/kg/day. Pt has PND15 w/IL infusing via central
PICC in (L)arm without incident. See flowsheet for Dsticks.
[**Name (NI) 4686**] remains to gravity, irrigates well, no output.
Abdomen exam is benign: Soft, pink, no loops. Active bowel
sounds. AG stable=20cm. Voiding qs, see flowsheet for U/O.
Passed mec stool. To place cottonball in diaper w/ 0400
cares for SCOR study. TO obtain Lytes on [**9-24**] AM. P:
COntinue to monitor and support infants nutrition. Team is
awaiting the "okay" from Surgery @ TCH in order to begin
feeds on this patient now that 14day [**Month/Year (2) **] course complete.

Hyperbili: Last bili drawn 24hrs ago = 5.6/0.6. Infant is
not under phototherapy. P: to obtain f/u bili w/ [**9-24**] Labs.

Sepsis: Pt. has completed a 14-day course of triple [**Month/Year (2) **]
(ampi/gent/clinda). NO s/sx of sepsis at this time. P:
COntinue to monitor pt for s/sx of sepsis.

CV: Soft murmur audible w/2200 cares =PFO by ECHO. HR =
140-160's thus far this shift. Infant is pink/ good pulses.
BP stable, See Carevue for BP's. HCT 28.4 prior to last
transfusion of PRBC's, which completed at 2100 this shift,
no rxn. F/U Hct to obtained with 8/11 labs. Infant is hemo-
dynamically stable at this time. P: Continue to monitor.

Refer to flowsheet for further details.


npn ccu
62 yo admitted to ccu for one hour s/p cath>tight lm ostial>or cabg
cp pain today went to pcp then for stress test-after 4min st down v4-6 to cath tight lm ostial, 50% prox rca stenosis, no sigificant other arteries, Iabp
pmhx-iddm, htn, +fam hx, remote smoking, tah/bso
allergy-pcn-hives
n-intact
r-bbsds cta breathing comfortable
cv-nsr 70 bp 140/80 on ntg at 20mcg's/ntg, iv hep 4500u>900u/hr, no filling pressures, easily palpable pedal pulses
foley
husband on his way in
a/p-severe lm ds for urgent cabg


MICU NPN 7A-7P
S/O: PT REMAINS [**Name (NI) 11492**]

RESP: WEANED PROPOFOL TO OFF AND TURNED PS FROM 15 TO 12. PT'S SBP AND HR INC SHARPLY AFTER PROPOFOL WEANED AND ABG POOR AFTER 40 MIN. PT'S BREATHING LABORED AND VERY DIAPHORETIC. RETURNED TO PS 15 AND PROPOFOL INC TO HELP PT SETTLE. ATIVAN 1 MG GIVEN PER NGT AND PROPFOL [**Month (only) 70**] AGAIN, WILL TRY TO WEAN PS TO 12 AGAIN AND ASSESS TOLERANCE. SUCTIONED X3 FOR SCANT THICK TAN SECRETIONS. LUNGS SOUNDS DECREASED BILAT. PIGTAIL CATHETER PULLED AND VASELINE GUAZE DRSG [**Name5 (PTitle) 51**].

CV: HYPERTENSIVE AND TACHY WITH PROPOFOL WEAN, OTHERWISE STABLE.

ID: AFEB, CEFTAZ AND VANCO DD/C'ED, LEVO STARTED.

GI: TF HELD TODAY FOR WEAN, NO STOOL, POS BS.

GU: CURRENTLY 200CC NEG. URINE CLEAR.

MS: PT C/O ANXIETY DURING WEAN, DAUGHTER STATES SHE IS SCARED THAT SHE WON'T BE ABLE TO WEAN OFF VENT. FAMILY IS IN ROOM CONSTANTLY. DR [**Last Name (STitle) **] AND I SPOKE TO FAMILY ABOUT LIMITING TIME IN ROOM BUT HUSBAND AND DAUGHTER INSIST THAT PT IS  LESS ANXIOUS WHEN FAMILY IS THERE. MANY APPROPRIATE QUESTIONS ASKED BY FAMILY.

A/P: FAILED WEAN THIS AM, WILL TRY AGAIN WITH MORE SEDATION. GIVE ATIVAN REGULARLY TO CONTROL ANXIETY. IF WEAN IS ATTEMPTED, NEED #5 AND #6 ETT IN ROOM AND PERHAPS ANESTHESIA IN ROOM. RACEMIC EPI ORDERED FOR IMMEDIATLY POST-EXTUBATION. [**Month (only) 12**] NEED TO SET LIMITS ON FAMILY IN A MEETING WITH THE ATTENDING AND SOCIAL WORKER IF FAMILY CONT TO BE AN ISSUE.


Sinus rhythm.  Compared to the previous tracing the ST segment elevation
in the inferior lead is much decreased (more than 50 percent) and the rate is
slower.
TRACING #2


[**2178-12-7**] 5:14 PM
 CT LOW EXT W/O C RIGHT                                          Clip # [**Clip Number (Radiology) 77055**]
 Reason: Eval frx and for ? mid-foot dislocation,
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


78 year old woman with MVC, and R ankle pain, swelling, deformity


REASON FOR THIS EXAMINATION:


Eval frx and for ? mid-foot dislocation,
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: JMGw MON [**2178-12-7**] 7:51 PM
  comminuted posteriorly displaced posterior calcaneal fracture. comminuted
  navicular fracture. comminuted distal fibular fracture. talar fracture at the
  level of the middle articular facet.
 ______________________________________________________________________________


FINAL REPORT


CT RIGHT LOWER EXTREMITY.


CLINICAL INDICATION:


A 70-year-old woman with MVC and right ankle pain,
 swelling, deformity.  Please evaluate for fracture.  Query mid foot
 dislocation.


TECHNIQUE:


MDCT was obtained to the right ankle with soft tissue and bone
 algorithms in axial, sagittal, and coronal planes.


FINDINGS:


No evidence of joint effusion.  Tibiotalar joint and mortise is congruent.
 There is an oblique comminuted fracture of the posterior process of the talus
 extending to the middle facet (sequence 106B, image 50).  In addition, there
 is an oblique, comminuted fracture at the anterior process of the calcaneus
 (sequence 106B, image 40), mild degree of medial displacement.  There is a
 transverse, minimally displaced fracture through the distal fibula (sequence
 107B, image 46).  At the navicular, there is a longitudinally oriented,
 complex comminuted fracture (sequence 107B, image 26).

 Tarsometatarsal joints are congruent with no evidence of dislocation.

 Visualized tendons are intact are grossly unremarkable. There is overall,
 diffuse osteopenia with mild mid foot arthrosis and a plantar calcaneal spur.


IMPRESSION:


1.  Oblique comminuted fracture of the posterior process of the talus
 extending into the middle facet.
 2.  Transverse fracture through the distal fibula.
 3.  Complex, comminuted longitudinally oriented fracture through the
 navicular.
 4.  Oblique fracture through the anterior process of the calcaneus.
 5.  No evidence of dislocation.

                                                             (Over)

 [**2178-12-7**] 5:14 PM
 CT LOW EXT W/O C RIGHT                                          Clip # [**Clip Number (Radiology) 77055**]
 Reason: Eval frx and for ? mid-foot dislocation,
 ______________________________________________________________________________


FINAL REPORT


(Cont)


Neonatology-[** 96**] Physical Exam

Infant remains orally intubated.  Active, sedated on fentanyl, phenobarb, generalized edema, AFOF, sutures opposed.  BBS coarse and equal, + air leak, good chest excursion.  No murmur, pulses +2, pink, RRR, remains on dopa.  Abdomen soft, round, active bowel sounds, NPO.  Please refer to attending progress note above for detailed plan.


Neonatology NP Note
PE
nested in isolette under phototherapy
AFOF, sutures opposed
mild-moderate subcostal retractions in NCO2, decreased air entry in bases be equal
RRR, no murmur,pink and well perfused
abdomen soft, nontender and nondistended, few bowel sounds
UVC in place
age appropriate tone and reflexes

Plan to institute CPAP


Sinus rhythm
Since last ECG, no significant change
Normal ECG


Demographics
   Day of intubation:
   Day of mechanical ventilation: 13
   Ideal body weight: 72.6.
   Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg
   Airway
   Airway Placement Data
   Known difficult intubation: No
   .
   Tube Type
   ETT:
                   Position: 25 cm at teeth
                   Route: Oral
                   Type: Standard
                   Size: 7.5m
   Lung sounds
   RLL Lung Sounds: Diminished
   RUL Lung Sounds: Clear
   LUL Lung Sounds: Clear
   LLL Lung Sounds: Diminished
   Secretions
   Sputum color / consistency: Tan / Thick
   Sputum source/amount: Suctioned / Moderate
   .
   Ventilation Assessment
   Level of breathing assistance: Continuous invasive ventilation
   Visual assessment of breathing pattern: Normal quiet breathing;
   Comments: occ overbreaths
   Assessment of breathing comfort: No response (sleeping / sedated):
   Invasive ventilation assessment:
   Trigger work assessment: Triggering synchronously
   Comments: occ overbreaths with rare alarm for high resp rate
   Plan
   Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated
   Reason for continuing current ventilatory support: Sedated / Paralyzed,
   Intolerant of weaning attempts, Cannot protect airway, Cannot manage
   secretions, Underlying illness not resolved; Comments: failed wean
   attempts
   ..
   .
   .
   .


Subjective
   Pending OR today.
   Objective
   Pertinent medications: Insulin SC, Pantoprazole, Fluconazole ,
   Meropenem, Heparin, Vancomycin, others noted
   Labs:
   Value
   Date
   Glucose
   111 mg/dL
   [**2113-8-22**] 02:45 AM
   Glucose Finger Stick
   124
   [**2113-8-21**] 10:00 PM
   BUN
   14 mg/dL
   [**2113-8-22**] 02:45 AM
   Creatinine
   1.2 mg/dL
   [**2113-8-22**] 02:45 AM
   Sodium
   134 mEq/L
   [**2113-8-22**] 02:45 AM
   Potassium
   4.2 mEq/L
   [**2113-8-22**] 02:45 AM
   Chloride
   102 mEq/L
   [**2113-8-22**] 02:45 AM
   TCO2
   24 mEq/L
   [**2113-8-22**] 02:45 AM
   PO2 (arterial)
   151 mm Hg
   [**2113-8-22**] 02:51 AM
   PO2 (venous)
   38 mm Hg
   [**2113-8-1**] 12:37 PM
   PCO2 (arterial)
   41 mm Hg
   [**2113-8-22**] 02:51 AM
   PCO2 (venous)
   55 mm Hg
   [**2113-8-1**] 12:37 PM
   pH (arterial)
   7.39 units
   [**2113-8-22**] 02:51 AM
   pH (venous)
   7.27 units
   [**2113-8-1**] 12:37 PM
   pH (urine)
   7.0 units
   [**2113-8-12**] 10:31 PM
   CO2 (Calc) arterial
   26 mEq/L
   [**2113-8-22**] 02:51 AM
   CO2 (Calc) venous
   26 mEq/L
   [**2113-8-1**] 12:37 PM
   Albumin
   2.1 g/dL
   [**2113-8-18**] 01:55 AM
   Calcium non-ionized
   8.4 mg/dL
   [**2113-8-22**] 02:45 AM
   Phosphorus
   3.0 mg/dL
   [**2113-8-22**] 02:45 AM
   Ionized Calcium
   1.12 mmol/L
   [**2113-8-22**] 02:51 AM
   Magnesium
   1.8 mg/dL
   [**2113-8-22**] 02:45 AM
   ALT
   181 IU/L
   [**2113-8-22**] 02:45 AM
   Alkaline Phosphate
   236 IU/L
   [**2113-8-22**] 02:45 AM
   AST
   71 IU/L
   [**2113-8-22**] 02:45 AM
   Amylase
   29 IU/L
   [**2113-8-19**] 02:04 AM
   Total Bilirubin
   3.2 mg/dL
   [**2113-8-22**] 02:45 AM
   Triglyceride
   240 mg/dL
   [**2113-8-8**] 02:00 AM
   WBC
   7.9 K/uL
   [**2113-8-22**] 02:45 AM
   Hgb
   9.4 g/dL
   [**2113-8-22**] 02:45 AM
   Hematocrit
   29.8 %
   [**2113-8-22**] 02:45 AM
   Current diet order / nutrition support: Tubefeeding: Replete with fiber
   Full strength;
   Starting rate: 40 ml/hr; Advance rate by 10 ml q4h Goal rate: 75 ml/hr
   Residual Check: q4h Hold feeding for residual >= : 200 ml
   Diet: NPO for Procedure except Meds, Start: After 12:01AM on date
   [**2113-8-22**]
   Do NOT resume diet after procedure. please hold TFs
   GI: Abdominal vac dressing intact with serous drainage
   Assessment of Nutritional Status
   70 year old male with complex hospital course, was on tube feed for
   full nutrition support.  Patient now with necrotizing pancreatitis,
   pancreatic drain in place with continuous irrigation, CT scan showed
   persistent pancreatic collection, patient on call to OR in am for


EXERCISE MIBI                                                   Clip # [**Clip Number (Radiology) 2551**]
 Reason: KNOWN CAD, S/P RECENT MI, IN NEED OF CATH, CREATININE ELEV. EVALUATE FOR REVERSIBLE PERFUSION DEFECT.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Known coronary artery disease, s/p recent myocardial infarction, in
 need of cath, but creatinine elevated.  Evaluate for reversible perfusion
 defect.

 SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:

 Exercise protocol:  Modified [**Doctor First Name 1658**].
 Resting heart rate:  76.
 Resting blood pressure:  130/84.
 Exercise duration:  3 minutes.
 Peak heart rate:  93.
 Percent maximum predicted heart rate obtained:  53%.
 Peak blood pressure:  200/82.
 Symptoms during exercise:  no symptoms.
 Reason exercise terminated:  fatigue and dyspnea.
 ECG


findings:


no ECG changes.

 INTERPRETATION:

 Imaging Protocol: Gated SPECT.
 Resting perfusion images were obtained with Tl-201.
 Tracer was injected 15 minutes prior to obtaining the resting images.
 Exercise images were obtained with Tc-[**Age over 90 **]m sestamibi.


FINDINGS:


The image quality is satisfactory.
 The study was interpreted using the 17-segment myocardial perfusion model. Left
 ventricular cavity size is dilated, but progressively dilated during stress.

 Stress images show a moderately severe reduction in photon counts involving the
 apex, as well as the apical segments of the anterior and inferior walls.
 Resting perfusion images show these defects to be partially reversible.

 Gated images reveal global hypokinesis, moderately severe.  Ejection fraction is
 reduced calculated at 30%.

 No prior studies are available for comparison.


IMPRESSION:


1) Large, moderately severe, partially reversible perfusion defect
 involving the apex, and apical segments of the anterior and inferior wall, at
 the level of exercise achieved.  2) Moderately severe global hypokinesis with
 reduced ejection fraction at 30%.

 Results were discussed with Dr. [**Last Name (STitle) 2552**], the resident physician caring for the
 patient, at 1:25 pm on [**2199-11-26**].

 /nkg

                                                             (Over)

 EXERCISE MIBI                                                   Clip # [**Clip Number (Radiology) 2551**]
 Reason: KNOWN CAD, S/P RECENT MI, IN NEED OF CATH, CREATININE ELEV. EVALUATE FOR REVERSIBLE PERFUSION DEFECT.
 ______________________________________________________________________________


FINAL REPORT


(Cont)

         [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 108**], M.D.
         [**Last Name (NamePattern5) 476**], M.D.              Approved: WED [**2199-11-27**] 9:46 AM


Events:
   Very agitated while on minimal sedation, near self extubation with
   profound leak, ETT was re-taped twice and pushed in down to 26 cm mark
   Sedation was increased up to 40 propofol and Neo gtt was started in
   parallel to keep MAP>60
   Billirubin 17
   Loosing considerable amnt of gastric secretion via Pedi tube
   ? Ischemic bowel on the last CT, lactate normal
   Plan to OR today with plastics (L. arm) and on Monday with surgery
   (abdomen)
   Impaired Skin Integrity
   Assessment:
   Multiple echymotic areas, blisters on L. hand, incision, open abdomen,
   l. arm fasiotomy
   Action:
   Turns, skin care, drains
   Response:
   Less moist, abd JP drain with less drainage
   Plan:
   To OR on Monday for abd closure. See NCP
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   LS dim at bases, desats to low 90s when needs to be suctioned, loosens
   up secretions with each turn, strong congested cough
   Action:
   ETT was re-taped, suction q1-2h for thick yellow sputum, CXR done,
   turns q2h, VAP protocol
   Response:
   Maintains sat>95
   Plan:
   Pulm toilet, see NCP


Clinical Nutrition
O:
~29 wk CGA BB on DOL 10.
Wt:  1125 g (+30)(~25th to 50th %Ile); birthwt:  1145 g.  WT currently down ~2% from birthwt
HC:  26.5 cm (~25th to 50th %Ile); last: 26.5 cm
LN:  37.5 cm (~25th to 50th %Ile) ;last:  36.5 cm
Labs noted
Nutrition:  150 cc/kg/day TF.  Feeds currently @ 70 cc/kg/day BM 20, increasing 10 cc/kg/[**Hospital1 **].  Remaining fluids as  PN via cnetral PICC line; projected intake for next 24 hrs from PN ~36 kcal/kg/day, ~3 g pro/kg/day; lipids d/c'd.  From EN: ~53 kcal/kg/day, ~0.8 g pro/kg/day, and ~3 g fat/kg/day.  GIR from PN ~5 mg/kg/min.
GI: Abdomen benign.  Soft transient loops.  Passing large meconium.

A/Goals:
Tolerating feeds so far without GI problems except transient loops.  Advancing slowly and monitoring closely for tolerance.  Tolerating PN with good BS control.  Labs noted and PN adjusted accordingly.  Current PN + EN meeting recs for pro/fat and vits.  Full kcals and mineral recs will not be met until feeds reach initial goal.  Growth should improve as feeds are advanced to initial goal.  Will  continue to follow w/ team and participate in nutrition plans.


[**2197-10-26**] 12:54 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 84906**]
 Reason: Evidence of acute change
 Admitting Diagnosis: TRANSIENT ISCHEMIC ATTACK
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


50 year old woman with anisocoria, left greater than right, confusional state


REASON FOR THIS EXAMINATION:


Evidence of acute change
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


anisocoria with left greater than right, confusional state.


COMPARISON:


[**2197-10-24**].


TECHNIQUE:


Noncontrast head CT.

 CT OF THE HEAD WITHOUT CONTRAST:  Since prior exam, there has been no
 significant interval change in the left frontoparietal intraparenchymal
 hematoma, now measuring 4.8 x 4.3 cm.  Persistent mass effect on the adjacent
 brain parenchyma and the left lateral ventricle.  The previously described
 hypodensity within the right lentiform nucleus appears slightly more
 conspicuous measuring 3.6 x 3.4 cm.  There is mass effect over the frontal
 [**Doctor Last Name 39**] of the right ventricle, which is unchanged since prior exam.  The
 visualized osseous structures are unremarkable.


IMPRESSION:


Unchanged left frontoparietal intraparenchymal hematoma with
 persistent mass effect.

 The previously described right lentiform nucleus hypodensity appears more
 conspicuous in this study and represents evolving infarct.  Further evaluation
 with MRI is recommended.


MICU/SICU NURSING NOTE 7P-7A:

SEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.

NEURO: PT REMAINS LIGHTLY SEDATED ON FENTANYL GTT @ 320 MCG/HOUR AND [** **] GTT @ 10 MG/HOUR.  OPENS EYES TO VOICE.  FOLLOWS SIMPLE COMMANDS.  PUPILS EQUAL/SLUGGISHLY REACTIVE.  DECREASED COUGH/GAG REFLEXES.

CV:  AFEBRILE.  SBP 100-160/60-80 BECOMES HYPERTENSIVE TO SBP 190 WITH SUCTIONING/TURNING.  HR 70-90 SR WITH NO ECTOPY.  HCT 27.7.  + 1 GENERALIZED EDEMA.  + PULSES.

PULM:  PT REMAINS INTUBATED ON PCV-28 IP 33 PEEP 14 WAS ON 70% FIO2 PT SATS DECREASED TO 91-92%.  ABG SENT 7.48/47/63/9/36.  MD AWARE FIO2 INCREASED TO 80%.  WILL RECHECK ABG.  LUNGS COARSE T/O.  SUCTIONING LARGE AMOUNT THICK WHITE SECRETIONS.

GI/GU:  ABD SOFT/DISTENDED HYPOACTIVE BOWEL SOUNDS. TUBEFEEDS INFUSING @ 70CC/HOUR (GOAL 80CC/HOUR) VIA OGT MINIMAL RESIDUAL.  -STOOL OVERNIGHT.  FOLEY DRAINING YELLOW/CLEAR URINE.

ENDOCRINE:  CONT TO CHECK FINGERSTICKS Q 6 HOURS AND COVER PER SSI.

PLAN:  ADANCE TUBE FEEDS AS TOLERATED, WEAN FIO2 AS TOLERATED FOLLOW ABGS, SURGERY CONSULT FOR POTENTIAL TRACH, CONT ANTIBIOTICS, CONT SEDATION FOR PATIENT [** **]. WILL CONT TO MONITOR.


Atrial fibrillation. Left bundle-branch block. Since the previous tracing
of [**2153-6-29**] no change.


80 year old man with 1 month history of R flank pain.  Went to OSH
   [**10-2**] and was sent home.  [**10-6**] back to OSH continued R flank pain.  CT=
   multi oculated mass in R retroperitoneum.  [**10-16**]  Ct direct biopsy that
   found heavy Pantoea. Pigtail placed.   [**10-31**] drains fell out returned
   to OSH.
   [**11-4**] tx to [**Hospital1 5**] R empyema and R retroperitoneum abscess
    [**11-7**] Arrived from [**Location 75**] S/P  R thoracoscopy, open R Thoracotomy with
   decortication
   Pleural effusion, empyema
   Assessment:
   3 CT and 2 pigtail placed in OR
   All tubes draining small amount sanginous
   HCT   28
   Action:
   frequent checks for CT drainage
   Response:
   minimal bloody drg
   Plan:
   Monitor Output
   Shock, hypovolemic or hemorrhagic
   Assessment:
   Pt lightly sedated on propofol
   follows directions consistently
   Denies pain
   Pacemaker interrogated post op
   V-paced with runs of V-tach
   Levophed and neo to keep SBP >90
   Action:
   unable to wean   pressors
   EKG
   lytes
   repleated
   Response:
   PT continues with Runs of Vtach
   Plan:
   Cont with current plan.
   Assess for


[**2182-10-1**] 10:05 AM
 PERC G/G-J TUBE PLMT                                            Clip # [**Clip Number (Radiology) 40446**]
 Reason: DID NOT PLACE PEG. DID FLOURO AND KUB ONLY. DUE TO BOWEL OVER STOMACH.
 Admitting Diagnosis: COPD FLARE,PNEUMONIA
 ********************************* CPT Codes ********************************
 * [**Numeric Identifier 2873**] FLUORO 1 HR W/RADIOLOGIST       [**Numeric Identifier 10955**] ABDOMEN SGL VIEW                 *
 ****************************************************************************
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


[**Age over 90 **] year old man with hx aspiration pna, s/p MICU stay, with anasarca, who had
  NG tube placed today and will need PEG [**10-1**]


REASON FOR THIS EXAMINATION:


Please place PEG on [**2182-10-1**]
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


A [**Age over 90 **]-year-old male with aspiration pneumonia and tube feeding
 dependence.  Please place percutaneous gastrostomy tube.


PROCEDURE:


The procedure was performed by Dr. [**First Name4 (NamePattern1) 546**] [**Last Name (NamePattern1) 547**] and Dr. [**First Name4 (NamePattern1) 1171**]
 [**Last Name (NamePattern1) 434**].  Dr. [**First Name (STitle) 434**], the staff radiologist, was present and supervising.  The
 patient was brought to the angiography suite and placed supine on the
 angiography table.  Fluoroscopic spot images were obtained.  Following this,
 the patient was transferred to the recovery room in stable condition.


FINDINGS:


Fluoroscopic spot images were obtained and, in conjunction with the
 CT of the abdomen obtained on [**2182-9-29**], confirmed the presence of the colon
 anterior to the gastric lumen. This prohibits safe access for percutaneous
 gastrostomy tube placement.

 COMPLICATIONS:  None.


IMPRESSION:


Multiple fluoroscopic spot images which, in conjunction with a CT
 of the abdomen dated [**2182-9-29**], demonstrate the presence of the colon anterior
 to the gastric lumen.  This does not allow for safe placement of a
 percutaneous gastrostomy tube.  If necessary, the feeding tube will need to be
 placed surgically.  These findings were discussed with the primary team at the
 time of the procedure.


Atrial fibrillation with a rapid ventricular response. Diffuse low voltage. The
prior tracing of [**2108-3-3**] suggested digitalis toxicity. The ventricular response
has now increased. Clinical correlation is suggested.


Demographics
   Day of mechanical ventilation: 5
   Ideal body weight: 69.9
   Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg
   Airway
   Tube Type
   Tracheostomy tube:
                   Type: Perc Trach
                   Manufacturer: Portex
                   Size: 8.0mm
   Cuff  Management:
                   Vol/Press:
                                   Cuff pressure: 28  cmH2O
   Lung sounds
   RLL Lung Sounds: Diminished
   RUL Lung Sounds: Clear
   LUL Lung Sounds: Clear
   LLL Lung Sounds: Diminished
   Secretions
   Sputum color / consistency: Blood Tinged / Thick
   Sputum source/amount: Suctioned / Small
   Ventilation Assessment
   Level of breathing assistance: Continuous invasive ventilation
   Visual assessment of breathing pattern: Normal quiet breathing
   Assessment of breathing comfort: No claim of dyspnea
   Invasive ventilation assessment:
   Trigger work assessment: Triggering synchronously
   Plan
   Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated.
   Wean to PSV as tolerated.
   Reason for continuing current ventilatory support: Underlying illness
   not resolved


[**2132-4-10**] 11:05 AM
 HIP UNILAT MIN 2 VIEWS LEFT                                     Clip # [**Clip Number (Radiology) 41743**]
 Reason: ?fracture
 Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


89 year old woman with AAA complaining of left hip pain and having point
  tenderness in the left hip


REASON FOR THIS EXAMINATION:


?fracture
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Evaluation of patient with left hip pain.


COMPARISON:


None available.


FINDINGS:


There is no evidence of distinct acute fractures or dislocations
 involving the left hip.  There is a prior lateral plate and fixation screws
 are visualized distally in the left femur.  Bilateral iliac bones have mottled
 appearance of nonspecific etiology.  Lower lumbar spinal fusion devices are
 seen.  Degenerative changes involving bilateral acetabular are visualized.
 Arterial calcifications are noted.


IMPRESSION:


1.  No evidence of acute fractures or dislocations.  MRI is the recommended
 study of choice if clinical suspicion for occult fracture is high.
 2.  Unusual mottled appearance of bilateral iliac bones,  of nonspecific
 etiology.


Atrial fibrillation
Ventricular premature complexes
Anterolateral myocardial infarct with ST-T wave configuration suggests acute
process
Consider inferposterior myocardial infarction, age indeterminate
Consider also chronic pulmonary disease/RV overload
Clinical correlation is suggested
No previous tracing for comparison


77 year old male with past medical history of lung cancer, DVT, and
   hypertension who presents with respiratory distress and
   unresponsiveness. Pt has failed extubation several times.  Is currently
   awaiting trach placement.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   Recurrent resp failure s/p failed extubation attempts x2.
   miltifacorial(new pneumonia, r hemidiaghragm extubation, likely due to
   prior surgical resection and volume loss) and absent gag. Pt initially
   scheduled for trach and peg placement in the or but cancelled  because
   pt r/I for nstemi last Wednesday and they want the procedure postponed
   for 1 week. Pt on 40% cpap with 5 peep and ips of 15
   Action:
   Pt medicated with 40 mg ivp lasix. No vent changes made. Suctioned ett
   for small to moderate amts of thick white to yellow sputum and orally
   for copious thick clear secretions. Lungs clear on auscultation but
   diminished at the bases.pt receiving vancomycin and meropenem for
   klebsiella coverage. Tube fdgs restarted at 1230 since pt will not go
   for surgical procedures till possibly Thursday. Resp precautions
   maintained.
   Response:
   Stable resp status and is confortable on fentanyl gtt  at 50mcg/hr  and
   versed gtt at 1mg/hr.  pt diuresing well with lasix but i&o still not
   neg .
   Plan:
   Goal for i&o is neg 1liter to 1
 liters. continue to wean vent as pt
   tolerates. Continue with inhalers as ordered and antibiotics as
   ordered. Continue  with resp  toileting. Plan is to meet with family
   tomorrow to discuss eventual  goals of care. If goal for neg fluid
   balance is not met may need to give additional doses of lasix
   Myocardial infarction, acute (AMI, STEMI, NSTEMI)
   Assessment:
   Hr better controlled on present medical regimen. Nstemi occurred in the
   context of reps distress tather than primary  event.
   Action:
   Pt receiving lopressor and captopril as ordered. Hemodynamics followed
   closely.  Continue with asa,and statins as ordered. Peg and trach
   placement placed on hold.
   Response:
   Hr now in the 60
s and sbp rnaging form 112-127
   Plan:
   Continue to follow hemodynamics closely. Transfuse for hct < 27. check
   electrolytes as ordered and replete as needed.


NPN 0700-1900


#2Resp:  Pt. remains in RA, RR 30-50's, sats > 94%.  Pt.
occas having periodic breathing.  Pt. had spell X 1 d/t
apnea & required [**Last Name (un) 377**] stim & BBO2.  LS clear bilaterally w/
midl SCR.  Pt. remains very pale & mottles w/ cares.  BP
WNL.  Transfusion consent signed & type & screen sent.  P:
cont to monitor closely.

#3FEN:  Pt. made NPO this am d/t lg aspirate, increased AG,
& lg neon green spit.  KUB done both supine & prone.
Surgery contact[**Name (NI) **] & will be in the assess today.  TF
120cc/kg/d of PND15 & D12.5 w/ hep infusing well through
central broviac.  D/S & electrolytes WNL.  Abd soft & full,
active bowel sounds.  Soft transient loop on RUQ evident @
8am but not at 12pm.  AG 28.5-29cm.  Pt. voiding qs &
stooling, guaic trace +.  NGT removed & replaced w/ repogle
to gravity [**Name8 (MD) 6**] [**Name8 (MD) 7**] orders.  P: remain NPO & cont to monitor
abd exam closely.

#4G&D:  Temps stable swaddled in OAC.  Pt. lethargic &
quietly [**Name8 (MD) **] w/ cares.  Pt. frowning when abd palpated.
Pt. sleeping in between cares.  MAE.  AFSF.  P: cont to
support dev needs.

#5Parenting:  [**Name8 (MD) **] & grandmother in most of day.  Mom
anxious & [**Name2 (NI) 102**] eyed.  Reassurance given.  Mom asking [**Name2 (NI) **]
questions.  Updates given by this RN & by [**First Name4 (NamePattern1) 4773**] [**Last Name (NamePattern1) 174**].  P:
cont to support & update.

#10CVL:  CVL C/D/I.  NO [**Last Name (NamePattern1) 4770**], edema, or drainage noted.
IVF infusing well.  P: cont to monitor.

#11Sepsis:  Pt. appearing sick, lethargic, & pale.  Pt.
continues on vanco & gent.  Vanco levels low & dose
increased.  [**Last Name (NamePattern1) **] cx pending.  P: cont on abx & monitor
closely.


[**2157-9-23**] 3:54 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 103178**]
 Reason: interval change
 Admitting Diagnosis: ABDOMINAL PAIN
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


57 year old man s/p sigmoid colectomy with retrocardiac atelectasis


REASON FOR THIS EXAMINATION:


interval change
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Sigmoid colectomy with left lower lobe atelectasis.


COMPARISON:


Multiple prior radiographs dating back to [**2157-8-29**] and most
 recently [**2157-9-22**].


FINDINGS:


A layering left pleural effusion is moderately large and has
 increased in size since [**2157-9-22**].  Left lower lobe atelectasis is stable since
 [**2157-9-2**].  The right lung is normal in appearance.  Cardiomegaly is moderate.
 A right internal jugular introducer sheath, tracheostomy tube and nasogastric
 tube are in satisfactory positions.


IMPRESSION:


Moderately large left pleural effusion which has slightly
 increased since [**2157-9-22**].  Satisfactory position of medical devices.


CARDIAC~APACED @ 88. UNDERLYING 45 SB.  NEO/NITRO. WEANED TO OFF. MAINTAINING SBP AROUND 115.  ELECTROLYTES REPLETED. POS PAL PEDAL PULSES BILAT.

RESP~ON  35% OFM. MAINTAINING SATS OF 96%. INS [**Location (un) 388**] & CDB EXERCISES.
LUNGS CLEAR UPPER DIM IN BASES.

NEURO~A&O X3. FC. MAE. MED W/ MORPHINE 2 MG X1/ PERCOCET 2 TABS X2, ALSO ON TORADOL 15 MG IM Q6. COMFORTABLE. REGLAN X 1 FOR C/O NAUSEA. EFFECTIVE.

GI/GU~TOL PO FLUIDS WELL. + BS. ADEQUATE U/O.

ENDO~CONT ON INSULIN GTT. TITRATING PER CSRU PROTOCOL.

A:CONDUCTION DISTURBANCE.
P: CONT TO A~PACE @ 88. [**Hospital 389**] REHAB. INSULIN GTT PER SCRU PROTOCOL. DELINE. D/C CHEST TUBES. CONT ICU INTERVENTIONS


Neonatology Attending

Day 46

Remains on CPAP at 6cm with fio2 0.25-0.3.  Coarse breath sounds.  RR 40-60.  Suctioned for large yellow nasal secretions.  Occasional saturation drifts related to secretions.  HR 160-180s.  PPS murmur.  BP mean 48.  Weight 1510 gms (+5).  On PE 30 with Promod.  Feeding infusion time shortened.  No evidence of intolerance.  Stable temperature- now in open crib.  No contact with [**Name2 (NI) 32**] over last day.

Adequate respiratory status on CPAP.  Will continue to monitor closely.  Gaining weight well overall.  Tolerating feeds well.  Will follow closely.


Chief Complaint: necrotizing pancreatitis, hypoxic respiratory failure
   24 Hour Events:
 SPUTUM CULTURE - At [**2146-1-31**] 08:30 AM
 ARTERIAL LINE - STOP [**2146-1-31**] 04:00 PM
 ARTERIAL LINE - START [**2146-1-31**] 04:00 PM
 ERCP - At [**2146-1-31**] 06:22 PM
 FEVER - 101.6
F - [**2146-2-1**] 04:00 AM
   - ARDSnet protocol, increasing PEEP, oxygenation stable, PaO2 ~80 on
   PEEP 18, FiO2 60 (current)
   - infected pseudocyst vs. cholangitis
   - receiving multiple fluid bolues, LR and NS
   - decision made for ERCP for eval of cholangitis -> no evidence of
   cholangitis, difficult to pass scope [**3-1**] edema
   - worsening oxygenation peri-procedure, increased to 100% FiO2
   - phenylephrine transiently during ERCP, back on levo 0.5, stable
   - plan for CT-guided aspirate of phlegmon with initial gram stain -> if
   (+), consideration for OR later tomorrow
   - paralyzed overnight with cisatracurium to improve synchrony with vent
   - pCO2 trended up, increased tidal volume to 450 cc
   - FFP x 3 for aspiratio
   - a-line clotted off this morning
   History obtained from Medical records
   Allergies:
   History obtained from Medical recordsMorphine
   hot
   sweating
   Last dose of Antibiotics:
   Fluconazole - [**2146-1-31**] 09:54 AM
   Vancomycin - [**2146-1-31**] 10:51 PM
   Piperacillin/Tazobactam (Zosyn) - [**2146-2-1**] 01:30 AM
   Infusions:
   Cisatracurium - 0.06 mg/Kg/hour
   Midazolam (Versed) - 20 mg/hour
   Fentanyl - 500 mcg/hour
   Other ICU medications:
   Pantoprazole (Protonix) - [**2146-1-31**] 08:30 AM
   Midazolam (Versed) - [**2146-1-31**] 11:20 AM
   Fentanyl - [**2146-1-31**] 11:30 AM
   Heparin Sodium (Prophylaxis) - [**2146-2-1**] 01:31 AM
   Other medications:
   Changes to medical and family


history:


unable to obtain [**3-1**] sedation
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Genitourinary: Foley
   Flowsheet Data as of  [**2146-2-1**] 07:55 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**48**] AM
   Tmax: 38.7
C (101.6
   Tcurrent: 38.2
C (100.7
   HR: 137 (137 - 160) bpm
   BP: 112/67(77) {81/45(59) - 129/72(81)} mmHg
   RR: 30 (18 - 36) insp/min
   SpO2: 94%
   Heart rhythm: ST (Sinus Tachycardia)
   Wgt (current): 127.9 kg (admission): 143 kg
    CVP: 11 (11 - 11)mmHg
   Bladder pressure: 12 (9 - 17) mmHg
   Total In:
                                                                 16,423 mL
                                                                  3,900 mL
   PO:
   TF:
   IVF:
                                                                 16,353 mL
                                                                  3,114 mL
   Blood products:
                                                                    786 mL
   Total out:
                                                                  2,060 mL
                                                                    695 mL
   Urine:
                                                                  1,410 mL
                                                                    695 mL
   NG:
                                                                    650 mL
   Stool:


[**2146-6-27**] 1:09 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 23401**]
 Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY
 Admitting Diagnosis: RAPID ATRIAL FIBRILLATION;MITRAL REGURGITATION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


79 year old woman with MVR


REASON FOR THIS EXAMINATION:


FAST TRACK EARLY EXTUBATION CARDIAC SURGERY
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


79-year-old female status post mitral valve replacement.


EXAMINATION:


Single frontal chest radiograph.


FINDINGS:


Interval support hardware has been placed including an nasogastric
 tube which terminates below with side port and tip below the diaphragm, an
 endotracheal tube terminating within the mid trachea, right internal jugular
 approach Swan-Ganz catheter with tip projecting over the main right pulmonary
 artery and left-sided pleural drains.  There has been interval placement of a
 mitral valve prosthesis.  A mediastinal drain has also been placed in standard
 position.  There is no evidence of pneumothorax or large pleural effusion.
 There is possible minimal pneumopericardium.  There is left lower lobe
 opacification, likely related to atelectasis and probable small effusion.
 There are no new focal opacities concerning for pneumonia.  The
 cardiomediastinal and hilar contours are stable, demonstrating mild
 cardiomegaly.


IMPRESSION:


Support hardware in standard positions.  No evidence of
 pneumothorax.


[**2185-5-23**] 11:26 AM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 37213**]
 Reason: please eval for CHF, PNA, infiltrates, etc
 Admitting Diagnosis: FEVER
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


68 year old man with hypoxia


REASON FOR THIS EXAMINATION:


please eval for CHF, PNA, infiltrates, etc
 ______________________________________________________________________________


FINAL REPORT


STUDY:  PA and lateral chest [**2185-5-23**].


HISTORY:


68-year-old man with hypoxia.  Evaluate for congestive heart failure
 or pneumonia.


FINDINGS:


A comparison is made to the previous study from [**2185-5-18**].

 There is a left-sided PICC line whose distal tip is seen to the level of the
 brachiocephalic/SVC junction.  This appears to have migrated more proximally
 since the previous study.  There remains bilateral pleural effusions.  The
 left base has improved in aeration.  There is also some mild prominence of the
 pulmonary interstitial markings. Bullous changes are seen within the left
 upper lobe.


[**2130-8-17**] 12:56 PM
 CT THORACENTESIS DRAINAGE; CT GUIDED NEEDLE PLACTMENT           Clip # [**Clip Number (Radiology) 57399**]
 Reason: RLL pleural effusion - is it an empyema?
 Admitting Diagnosis: PNEUMONIA
 ********************************* CPT Codes ********************************
 * CT THORACENTESIS DRAINAGE             CT GUIDED NEEDLE PLACTMENT             *
 ****************************************************************************
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


67 year old woman with hx of COPD, SCLC now with PNA and RLL effusion
  concerning for empyema


REASON FOR THIS EXAMINATION:


RLL pleural effusion - is it an empyema?
 No contraindications for IV contrast
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): [**First Name9 (NamePattern2) 57400**] [**Doctor First Name 141**] [**2130-8-17**] 4:15 PM
  CT-guided thoracentesis of left lower pleural fluid loculated collection.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


67-year-old woman with pneumonia and pleural effusion with
 loculation and rim enhancement suggestive of an empyema.


COMPARISON:


Chest x-ray from [**2130-8-14**] and CT from [**2130-8-12**].


FINDINGS:


A preliminary non-contrast CT scan through the lung bases reveals
 right lower lobe consolidation and a right pleural effusion.  A focus of
 intrapleural gas is again located within it, suggesting that there may be, or
 have been, a bronchopleural fistula in the absence of prior instrumentation.
 However, the amount of gas is less than on the prior study, which may indicate
 that a fistula, if one has been present, has closed.  No new pleural gas is
 seen.  The pleural effusion appears also similar to slightly smaller.


PROCEDURE:


Informed consent was obtained.  A pre-procedure timeout was
 performed using two forms of patient identification.  The patient was placed
 prone, and the back was prepped and draped in the usual sterile fashion.
 Anesthesia was administered using 75 mcg of Fentanyl intravenously.  The
 patient's hemodynamic parameters were continuously monitored throughout the
 procedure by the radiology nursing staff.

 The skin and subcutaneous tissues were anesthetized with 1% buffered lidocaine
 solution.  Then using CT guidance, an 18-gauge [**Last Name (un) 2948**] needle was advanced
 into the pleural space at the left posterior base below the consolidated lung,
 and clear straw fluid (about 10 cc) was first obtained, followed by pink-
 tinged but clear fluid (about 20 cc). At this point, we talked to the
 referring team and it was decided not to deploy a drain, as the fluid was felt
 likely transudative.

 However, an attempt was made to aspirate more fluid for symptomatic relief.
 Using CT guidance, a 5-French [**Last Name (un) 655**] catheter was advanced at the same site and
 with the same approach into the residual fluid.  Some air was present in the
 adjacent pleural space which had been introduced by the first needle.  This
 was mostly evacuated, and subsequently about 25 cc of additional pink-tinged
 fluid was obtained, less than had been expected, with a small focus of mucoid-
                                                             (Over)

 [**2130-8-17**] 12:56 PM
 CT THORACENTESIS DRAINAGE; CT GUIDED NEEDLE PLACTMENT           Clip # [**Clip Number (Radiology) 57399**]
 Reason: RLL pleural effusion - is it an empyema?
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 appearing material at the end. Under fluoroscopy, the degree of effusion at
 the level of the right lung base appeared nearly resolved, and it could be
 that this area was more loculated than had first appeared, leaving small
 loculations elsewhere that do not communicate well.  Septations within fluid
 collections are frequently not visualized on CT.

 Samples were sent for chemistry, hematology, and microbiology studies.  The
 patient tolerated the procedure well.  There were no immediate complications.
 Dr. [**First Name (STitle) 860**], the attending radiologist, supervised the entire procedure.


IMPRESSION:


1.  CT-guided thoracentesis of posterior portion of left pleural effusion.

 2.  Note that pre-existing air in the pleural space suggests a bronchopleural
 fistula may have been present at some point, in the absence of prior
 intervention.  However, the decreasing amount of gas suggests that if
 previously present, it may have resolved.


Sinus rhythm. Borderline first degree A-V delay. Left atrial abnormality. Left
axis deviation. Probable left anterior fascicular block. Since the previous
tracing of [**2176-9-30**] no significant change.


NPN-MICU
Mrs.[**Known lastname **] has made no improvement tonight
Neuro: pt cont to be min rsp except to noxious stimuli(ie:sx,turning). She has not followed commands and there is little extrem movement. No sedation meds given. She cont to grimace to any and all movement, PERLA
CV: Pt did not tol a further wean of her NEO to <1mcg/kg/min  and in fact her BP has dropped to MAPS <65 so the Neo has been increased to 2mcg/kg/min. There is no apparent reason for the drop. u/o is still nothing and temp is at 97. She cont on IVAB that are level dosed per renal function.
Resp:secretions appear to be sl increased, thicker and yellow. O2 sats are good and there have been not vent changes. Unsuccessful at Aline [**Last Name (LF) 10522**], [**First Name3 (LF) **] no ABG checked.
GI:asp per NGT are down but still no stool and  neg BS.
Skin:she cont to weep s/s fluid from open areas on arms.
A/P:little progress made, Will cont to asses mental staus now off sedation
    Will cont to wean NeO if able
    Cont with IVAB, checking levels this am
    Follow NGT asp and ?TPN vs TF
    Await decision re:HD
    Pulmonary toilet as able


Respiratory Care
Pt weaned to pcv of 20, IP of 20, peep 20, rate 42, 50%. Pt off paralytics, Sating well, ABG on above setting 738/50/78/31/2/97. Suctioning bleed tinged secrections. MDIs as ordered.


Sinus tachycardia. Compared to the previous tracing of [**2109-5-22**] the rate has
increased. The Q-T interval has decreased and the non-specific lateral T wave
inversions are no longer seen.


NPN 1900-0700


Resp O/A: Remains on nasal prong CPAP 5, 21%. Lungs c/=.
Mild ic/sc retractions. 3 spells so far this shift, apneic,
QSR/mild stim. Remains on caffeine. P: Continue to monitor
for A/B/D's.

FEN O/A: BW 1275g. CW 1210g, up 20g. TF 130cc/k/d BM26 with
bp, = 28cc q4h, pg x1hr. Abd benign, full, soft. Girths
21-22.5cm. No spits, min asp. Voiding qs, small stools.
Small amt breakdown noted on bottom. On iron and vit e. P:
Continue to pg feed q4h. ? desitin to bottom.

G&D O/A: Temps stable, nested with ss in servoisolette.
Active/[** 96**] with cares. AGA. MAE. Font s/f. Sucks pacifier,
settling well tonight. Sm amt yellow right eye drainage this
shift- cleaned with sterile water, warm soak applied. P:
Continue to monitor and support normal infant development.

Parents O/A: Mom called x1. Updated by this RN. Invested and
appropriate. Plans to be in for 10am care. P: Continue to
update, educate, and support NICU family.


NURSING PROGRESS NOTE 1900-0700
REPORT RECEIVED FROM AM SHIFT.  ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.

NEURO:  PT ALERT AND ORIENTED X 2- AWARE OF SELF AND PLACE- NEEDS REORIENTATION OF TIME AND DATE.  PT IS STARTING TO GET DAYS AND NIGHTS CONFUSED- WATCHING FOR INCIDENCES OF ICU PSYCHOSIS.  PT HAS BEEN APPROPRIATE THROUGHOUT THE SHIFT.  SOFT SPOKEN AT TIMES BUT SPEECH IS CLEAR.  AFEBRILE.  PERRLA, 3 BRISK.  MAE X 4- ABLE TO LIFT AND HOLD.  RT SIDE IS WEAKER THAN LEFT.  IS ATTEMPTING TO ASSIST WITH TURNS AND PM CARE.  ICP 4-5.  VENTRICULOSTOMY IS SECURE AND PATENT.  AT 5CM ABOVE THE TRAGUS.  CONTINUES TO DRAIN CLEAR CSF 10-20CC/HR.  C/O SLIGHT BACKACHE- GIVEN PRN MS04 IV WITH THERAPEUTIC RESULTS.  [** **].  ABLE TO FOLLOW COMMANDS CONSISTENTLY.

RR:  BBS= ESSENTIALLY COARSE TO UPPER LOBES AND DIMINISHED TO BILATERAL LOWER LOBES.  COUGH EFFORT IS STARTING TO GET STRONGER.  NT SUCTIONING IS PRODUCTIVE FOR THICK, YELLOW SECRETIONS.  CXRAY OBTAINED THIS AM TO DETERMINE PNA STATUS.  BILATERAL CHEST EXPANSION NOTED.  RR 15-20 AND REGULAR.  UNLABORED.  NO C/O DIFFICULTY BREATHING OR SOB.  SP02 > OR = TO 94%.  PT DOES NOT TOLERALTE O2 WELL- STATES THAT IT MAKES HIM "SICK TO THE STOMACH".  IN VIEW OF PT'S VOMITING EPISODE AND BOUTS OF NAUSEA- DC'D.  PT HAS DONE WELL ON RA.

CV:  S1 AND S2 AS PER AUSCULTATION.  DENIES ANY CHEST PAIN.  HR 90-100'S.  NSR-NST WITH NO SIGNS OF ECTOPY NOTED.  SBP > OR = TO 100.  NO HYPER OR HYPOTENSIVE CRISIS NOTED.  CONTINUES ON HYDRALIZINE, VASOTEC AND LOPRESSOR AS SCHEDULED.  HAS NOT NEEDED ANY PRN ANTIHYPERTENSIVES THIS SHIFT.  PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS PEDIS.  LT RADIAL ALINE IS SECURE AND PATENT.  RECALIBRATED AND REZEROED DURING THE SHIFT.  LT SCL CVL IS SECURE AND PATENT.  BROWN PORT HAS CLOTTED OFF- TAPED OVER TO PREVENT ACCIDENTAL USAGE.

GI:  ABD IS SOFT, SLIGHTLY DISTENDED, NON-TENDER TO PALPATION.  PT HAD EPISODE OF VOMITING APPROXIMATELY 300CC OF BROWN LIQUID.  TF DC'D FOR THE EVENING, GIVEN TOTAL OF 4MG OF ZOFRAN AND NGT TO LIS.  PT HAS DONE WELL WITH THESE INTERVENTIONS- NO OTHER EPISODES OF N/V/D.  DR. [**Last Name (STitle) **] MADE AWARE.  NO BM THIS SHIFT.  HYPOACTIVE BS X 4 QUADRANTS.
PT HAS BEEN POSITIONED ON HIS SIDES TO PREVENT ASPIRATION.

GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT.  CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.

INTEG:  NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.

SOCIAL:  BOTH BROTHERS IN TO VISIT.  ALL QUESTIONS AND CONCERNS DISCUSSED.  NO ISSUES.

PLAN:  CONTINUE NEURO CHECKS.  PROVIDE COMFORT AND REORIENTATION.  PLS. SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION.  THANK YOU.


Neonatology - NP Pysical Exam
Awake and [** **] with cares, temp stable in open crib. In room air, BS clear and equal with symmetrical chest movement, color pink. RRR, without murmur (hx of murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Normal female genitalia. Without rashes. Please see attending neonatologist note for detailed plan of care.


Sinus bradycardia, rate 52.  Otherwise, normal tracing.  No previous tracing
available for comparison.


Chief Complaint:
   24 Hour Events:
   - appeared grimacing, in pain in AM--> gave .75 mg dilaudid (no
   effect)-->1 mg dilaudid, resting comfortably (sleeping but breathing)
   - called neuro, ordered EEG
   - g-tube study NL - re-started TF (changed formula per nutrition), but
   unable to advance rate 2/2 residuals
   - neuro concerned for new stroke (no doll's eyes to R)-->ordred MRI
   - updated brother regarding all of the above
   Allergies:
   Metformin
   Unknown;
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Morphine Sulfate - [**2156-2-18**] 11:20 AM
   Hydromorphone (Dilaudid) - [**2156-2-18**] 10:00 PM
   Heparin Sodium (Prophylaxis) - [**2156-2-19**] 08:03 AM
   Other medications:
   Changes to medical and family


history:


Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2156-2-19**] 08:04 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**57**] AM
   Tmax: 37.2
C (98.9
   Tcurrent: 37.2
C (98.9
   HR: 93 (84 - 102) bpm
   BP: 128/53(69) {98/30(47) - 140/71(93)} mmHg
   RR: 16 (10 - 40) insp/min
   SpO2: 100%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 62.5 kg (admission): 64.3 kg
   Height: 65 Inch
             Total In:
                                                                    181 mL
                                                                    447 mL
   PO:
             TF:
                                                                    121 mL
                                                                     19 mL
   IVF:
   328 mL
   Blood products:
   Total out:
                                                                      8 mL
                                                                      0 mL
   Urine:
   NG:
                                                                      8 mL
   Stool:


NPN 0700-1900


#1SEPSIS: Temp stable. Infant remains on Ampicillin and
Cefotaxine. 72 hour blood culture is negative. Entero virus,
HSV, PCR pending. Infant is pale in color; CBC sent; crit
35.4, PLT 193, retic pending, diff pending. A/P:Continue
with antibiotics as ordered, Continue to monitor for signs
and symptoms of infection.

#2DEVE: Breast feeding and bottling ad lib demand well.
Bottling 65-70cc's. Temp stable. Infant is swaddled in the
OAC. Alert and active with cares. Sleeps well in between.
Settles well with cares. MAE. Fontanels are soft and flat.
Brings hands to face. A:AGA P:Continue to support growth and
development of infant

#3PAERNTING: Mom in for afternoon cares. Very loving toward
infant. Asking appropriate questions. Update given by RN and
NNP Zac at the bedside. A:Loving P:Continue to support and
educate

#4RESP: Infant placed in NC 13cc's at 100% at 1400 for
several desats to the 79-87 while sleeping. Periodic
breathing noted. Lung sounds are clear/=. No retractions
noted. RR=30-50's, sats 96-99%. No desats while in NC. No
spells. A:NC P:Continue to monitor for spells, continue to
wean out of NC as tolerated.

#5CV:Irregular heart rate audible. Rythmn strip done at
bedside. NNP aware and examined strip. Several PAC's noted.
No murmur heard. Infant is pale. P:Continue to monitor for
PAC's and possible EKG tomorrow.


Sinus rhythm. Baseline artifact and wandering baseline. Low limb lead voltage.
Non-specific ST-T wave flattening in the limb leads. The T waves are biphasic
to inverted in leads V2-V5 consistent with active anterolateral ischemic
process. The Q-T interval is prolonged. Followup and clinical correlation are
suggested. No previous tracing available for comparison.


T/SICU NPN-
Brief ROS-

[**Name (NI) 8826**] Pt. has propofol running at 60mcg. He has remained reletively sedated but occ lightens enough(with stimulation) to move arms towards ETT, puposeful movements. PERL. Rcv'd fentanyl 100mcg during GI procedure.

Resp- Remains fully vented this shift. No secretions when suctioned this shift. Resp alkalosis corrected with vent change- changed to SIMV, TV decreased to 550(from 600), rate dropped from 12 to 10, cont on [**5-19**] PS and PEEP. Spont breaths 0-6 over vent. Breath sounds are clear bilat.

CV- Stable BP, brief dip with fentanyl. SR, no ectopy noted. Repleting magnesium(1.9). Hct has remained stable, last 34 (from 32.6 and 33).Angio sit intact, no hematoma. Dopplerable periph pulses. Rt SC central line remains in place. Rt arm PICC line in place as well.

Endo- No coverage required for FS BS in the 80's.

GI- GI Tm here at 5-6:30pm to do endoscopy. No new areas of bleeding per tm, believed that accumulated bld may be from esoph tear r/t vommiting. Lower GI shows no sign of bleeding. Abd soft with +BS earlier in shift. After endoscopy pt. had lrg amt of flatus as well as lrg amt of liq brn stool, very odorous. Abd has since been sl distended.

GU- Adequate u/o via foley.

ID- +VRE in his bile. Started e-mycin today. Afeb.


NPN nights


Alt in RESP:  Infant continues in RA, lungs clear and equal,
mild SC retraction, RR 30-70's, O2 sats 88-100 - mostly in
high 90's.  Occasional drifts with gavage feedings - QSR.
No spells tonight.  continues on caffeine.  Stable resp
status. will continue to monitor closely.

Alt in DEV:  Temps stable in air mode [** 627**], dressed and
swaddled.  ACtive and alert with cares, moving all
extremties, brings hands to face, sucks on pacifier.  AGA.
will continue to support developmental needs.

F/N:  weight tonight 1410g up 40g.  TF 150cc/k/d of BM30
with promod.  All gavage feeds, given Q 4hours via ngt over
90min.  ABdomen is soft, pink, active bowel sounds, voiding
and [** **] , AG stable.  no spits, residuals less than
1cc. Tolerating feeds well, and gaining weight, will
continue with current feeding plan and monitor.

Parenting:  mother called , updated, plans to be in at 4pm .


Ventricular paced beat followed by regular rhythm - probably sinus tachycardia
with first degree A-V delay
Intraventricular conduction delay - probably left bundle branch block
Poor R wave progression - could be due in part to intraventricular conduction
delay/ left ventricular hypertrophy but consider also prior anteroseptal
myocardial infarction
Diffuse ST-T wave abnormalities
Since previous tracing of [**2159-9-25**], bradyarrhythmia now absent


TITLE: PHYSICIAN RESIDENT PROGRESS NOTE
   Chief Complaint:
   24 Hour Events:
   -Vanco dose adjusted based on renal function
   -Normotensive; Did not receive captopril
   -Failed a trial of PS
   Allergies:
   Penicillins
   Rash;
   Codeine
   Rash;
   Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)
   Rash;
   Last dose of Antibiotics:
   Vancomycin - [**2150-12-16**] 09:38 AM
   Ceftazidime - [**2150-12-17**] 10:00 PM
   Infusions:
   Fentanyl (Concentrate) - 100 mcg/hour
   Midazolam (Versed) - 3 mg/hour
   Other ICU medications:
   Lansoprazole (Prevacid) - [**2150-12-17**] 10:36 AM
   Heparin Sodium (Prophylaxis) - [**2150-12-17**] 04:40 PM
   Midazolam (Versed) - [**2150-12-17**] 08:30 PM
   Fentanyl - [**2150-12-17**] 08:30 PM
   Other medications:
   Changes to medical and family


history:


Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2150-12-18**] 07:19 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.4
C (99.4
   Tcurrent: 37.1
C (98.7
   HR: 91 (69 - 111) bpm
   BP: 134/72(95) {88/47(61) - 150/80(103)} mmHg
   RR: 21 (12 - 21) insp/min
   SpO2: 98%
   Heart rhythm: AF (Atrial Fibrillation)
   Wgt (current): 82.5 kg (admission): 81.3 kg
   Height: 60 Inch
    CVP: 8 (8 - 14)mmHg
   Total In:
                                                                    836 mL
                                                                    420 mL
   PO:
   TF:
                                                                     81 mL
                                                                    160 mL
   IVF:
                                                                    420 mL
                                                                    160 mL
   Blood products:
   Total out:
                                                                  1,060 mL
                                                                    450 mL
   Urine:
                                                                  1,060 mL
                                                                    450 mL
   NG:
   Stool:


Respiratory Care
Pt cont on prong CPAP. Fio2 .26-.34. bs clear, rr 40-60 with mild retractions. Started on caffeine for spells. Pt had total of 5 spells thus far this shift. Plan to support as needed. Will follow.


Respiratory Care
Pt remains trached and on vent support. Trach is a # 7.0 portex. Vent changes were A/C to PSV due to spont breaths. PS was dropped from 16 to 14 and pt required A/C later do to tiredness. L.Sounds wer clear to course t/o and dim the bases. Suctioned for scant-small amounts of thick blood tinged secretions. MDI's received with good effect. Care plan is to continue therapy and wean to PSV as tol. Will continue to follow pt.


[**2101-11-1**] 6:04 PM
 CTA CHEST W&W/O C &RECONS                                       Clip # [**Clip Number (Radiology) 85849**]
 Reason: hematoma v. atelectasis around arota
 Admitting Diagnosis: FAHH;SUBARACHNOID HEMATOMA
  Contrast: OPTIRAY Amt: 100
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


89 year old woman hypoxia and widened mediastinum seen on cxr today.


REASON FOR THIS EXAMINATION:


hematoma v. atelectasis around arota
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


89-year-old woman with hypoxia, and abnormal chest x-ray.  Please
 assess mediastinum.


COMPARISON:


Chest x-ray from the same day.


TECHNIQUE:


Multidetector CT scanning of the chest was performed before and
 after the administration of intravenous contrast.  Following the non-gated
 chest pain protocol.  Coronal and sagittal reformations were obtained.

 CT OF THE CHEST:  There is fusiform aneurysmal dilation of both the ascending
 and the descending thoracic aorta, as well as a more focal region of saccular
 aneurismal dilation of the descending aorta, measuring upto 4.6 cm. However,
 there is no evidence of mediastinal hematoma. The tortuous contour of the
 aorta corresponds to the plain film findings.

 The heart is enlarged. There is extensive calcification of the aortic valve as
 well as coronary artery calcifications. No central or segmental filling
 defects are identified within the pulmonary arteries.  A right humerus
 replacement creates artifact, obscuring the lateral soft tissues on this side.
 There is no evidence of pathologic mediastinal, hilar, or left axillary
 lymphadenopathy.

 The lungs demonstrate bibasilar atelectasis with some air bronchograms in both
 lower lobes. Part of this atelectasis does abut the descending aorta.  The
 increased density in the upper lobes likely relates to submaximal
 inspiration.  No pleural effusions are identified.

 The superior aspect of the liver, spleen, and stomach appear unremarkable.
 Cystic structures are seen in both kidneys, which are incompletely evaluated,
 however, the largest measuring 4 cm seen in the upper pole of the left kidney
 is a simple fluid attenuation.

 OSSEOUS STRUCTURES:  There is extensive degenerative change of the spine,
 including a compression deformity of one of the lower thoracic vertebral
 bodies.  The degenerative disease creates a mild left convex thoracic
 curvature of the spine.  No concerning lytic or sclerotic lesions are
 identified.


IMPRESSION:


1.  Aneurysmal dilation of the ascending and descending aorta, measuring up to
                                                             (Over)

 [**2101-11-1**] 6:04 PM
 CTA CHEST W&W/O C &RECONS                                       Clip # [**Clip Number (Radiology) 85849**]
 Reason: hematoma v. atelectasis around arota
 Admitting Diagnosis: FAHH;SUBARACHNOID HEMATOMA
  Contrast: OPTIRAY Amt: 100
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 4.6 cm in diameter, and corresponding to the abnormal mediastinal contours on
 the recent chest plain film. No evidence of mediastinal hematoma.
 2.  Bibasilar atelectasis.
 3.  Cardiomegaly; calcification of coronary arteries and the aortic valve.
 4.  Incompletely characterized cysts in both kidneys.  The largest of these is
 a simple cyst. Renal ultrasound may be considered if warranted clinically.


[**2136-7-10**] 1:57 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 13096**]
 Reason: recent abrupt desaturation, rule out acute process
 Admitting Diagnosis: PELVIC FX
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


62 year old man with R ptx


REASON FOR THIS EXAMINATION:


recent abrupt desaturation, rule out acute process
 ______________________________________________________________________________


FINAL REPORT


EXAMINATION:


Portable chest x-ray.


CLINICAL INDICATION:


Recent abrupt desaturation, assess for an acute process.


FINDINGS:


Single portable x-ray of the chest was obtained and compared to the
 prior examination dated [**2136-7-9**] at 7:32.  There is a new left basilar
 opacity obscuring the left hemidiaphragm.  Streaky opacities are again noted
 at the right base that are slightly more prominent than the prior examination.
 A small right-sided pneumothorax is present.  The cardiomediastinal silhouette
 is grossly unchanged.  Median sternotomy wires are again noted.


IMPRESSION:


1.  New left basilar opacity likely represents atelectasis and/or pneumonia.
 2.  Small right pneumothorax.
 3.  Interval progression of right basilar streaky opacities with an appearance
 most consistent with underlying atelectasis.


Nursing Progress Note 0700-1900
Review of Systems:

Neuro: Pt remains sedated on Versed @ 3mg/hr, Fentanyl @ 70mcg/hr. Pt intermit opens eyes to voice. No spont movement of extremeties noted. Pt without evidence of pain/discomfort.

Resp: Pt has remained on vent settings 20 X 350/ +12/70%, sating 96->89%. Rare spont respirations. Sats dropped to low 80's with turning STS, returned to 89/90% after repositioning and suctionning. Suctionned for mod amts thick/yellow secretions. Lung snds coarse throughout.

CV: HR 64-77SR without ectopy, BP 88/41-97/47. Heparin qtts cont @ 1150u/hr, with 0830 PTT 66.4.

GI: TPN [**E-mail address 2920**]/hr. Bowel snds hypoactive, no stool this shift.

GU: Urine yellow/clear, draining via foley @ 30-80ml/hr.

ID: Temp 101.2po. Given Tylenol 650mgPR X 1 with poor results. Antibiotic tx unchanged from Vanco, Flagyl, Levofloxacin.

Social: Caregiver from group home, [**Doctor Last Name **], @ [**Doctor Last Name **]. Brothers to arrive this pm to discuss [**Name (NI) 190**]. NE Organ Bank personel aware.


TSICU
   HPI:
   87F passing clots and bright blood per rectum.  Initial crit 18, TEM's
   on [**6-23**]; flex sig demonstrating large amount of adherent clot, no active
   source of bleeding.
   Chief complaint:
   BRBPR
   PMHx:
   PMH: Rectal ca s/p chemorads, AFib, DMII, glaucoma, cataracts, HPL
   PSH: Transanal endoscopic rectal mass resection
   [**Last Name (un) **]: Diltiazem 100', Lasix 40 [**Doctor First Name **]/Tu/Th/Sat, Lasix 20 M/W/F, Vit C 250',
   FeSO4 325', Metoprolol 25'', VitD 300U'', TUMS 500''', Lipitor 10 qHS,
   Travatan 0.004% qHS, Cosopt'', Combivent INH'', Genteal eye gtt''', ISS
   Soc: She has a remote history of tobacco use, denies EtOH & illicit


Possible ectopic atrial rhythm
Short P-R interval
Lateral ST-T changes suggest myocardial injury/ischemia
Since previous tracing of [**2180-12-16**], the heart rate is faster, P wave not seen


Sinus tachycardia. Rightward axis. Non-specific ST-T wave abnormalities.
Compared to the previous tracing of same date there is no significant change.
TRACING #2


Neonaotlogy Attending
DOL 9

Remains in room air with one bradycardia in 24 hours.

No murmur. BP 65/36 (47).

Wt 2120 (+85) on TFI 150 cc/kg/day BM/SC24, tolerating over 90 minutes by gavage. Abd benign. Voiding and stooling normally (guiac negative).

Temp stable in air isolette.

A&P
31-1/7 week GA [** 168**] with respiratory and feeding immaturity
-No changes in management as detailed above


[**2188-12-5**] 7:11 AM
 NEONATAL HEAD PORTABLE                                          Clip # [**Clip Number (Radiology) 104118**]
 Reason: INFANT BORN AT 24 WEEKS,HX OF RT IVH WITH PARENCHYMAL EXTESION, FOLLOW IVH
 Admitting Diagnosis: NEWBORN
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


Infant born at 24 weeks gestation,
  history of right IVH with parenchymal extension


REASON FOR THIS EXAMINATION:


follow ivh
 ______________________________________________________________________________


FINAL REPORT


NEONATAL HEAD ULTRASOUND:


HISTORY:


Infant born at 24 weeks gestation.  History of right
 intraventricular hemorrhage with parenchymal extension.  Follow-up
 intraventricular hemorrhage.


FINDINGS:


Since the examination of [**2188-12-1**], there has been evolution of the
 bilateral intraventricular hemorrhage.  The extension of the parietal
 parenchyma is again noted.  The amount of extension to the right
 periventricular white matter with cystic changes is similar to the prior
 examination.  No new hemorrhage is seen.  The amount of intraventricular blood
 is again noted to be more on the right than on the left.  There resistive
 indices are very similar to the prior examination, that is without compression
 ranging from 0.66 to 0.76 and then with gentle compression ranging from 0.78
 to 0.9.  The cystic changes seen in the right periventricular white matter are
 more prominent, because the clot has evolved within it leaving the cystic
 lucency to appear more conspicuous within it.  The right lateral ventricle has
 increased in size and the left lateral ventricle has decreased in size.


IMPRESSION:


Evolution of the bilateral intraventricular hemorrhage with a mild increase in
 the size of the right lateral ventricle and decreased in the size of the left
 lateral ventricle.  Due to the evolution of the hemorrhage, the cystic changes
 in the right periventricular white matter appear more conspicuous but overall
 not increased in geographic size.  No new bleed.  Resistive indeces
 essentially similar to the prior examination.


NURSING PROGRESS NOTE
NURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS.

NEURO: SEDATED ON PROPOFOL. AROUSES TO VOICE. ATTEMPTING TO MOUTH WORDS TO MAKE NEEDS KNOWN. APPEARS TO NO APPROPRIATELY TO YES/NO QUESTIONS. PERRLA, BRISK. MAE WITH EQUALLY STRONG-PURPOSEFUL MOVEMENT. +GAG/COUGH. C/O INCISIONAL PAIN. MEEDICATED IVP MORPHINE WITH GOOD RELIEF.

CARDIAC: HCT: 28.6. NSR. HR: 70-80'S. NIBP: 97-136/40-48. CVP: [**9-15**].
+RADIAL, BRACHIAL,FEMORAL,PT AND DT VIA DOPPLER. CSL.

PULM: INTUBATED ON AC/50%/500/16/5 PEEP. POX: 99-100%. NO ABG [**Name8 (MD) **] MD [**Last Name (Titles) **]. LS: CLEAR THROUGHOUT. SX FOR SCANT AMT OF THICK WHITE SECRECTIONS.

GI: NPO. L-NARE NGT TO CLW SX WITH MODERATE AMT OF THICK GREEN BILIOUS DRAINAGE. IRRIGATED X2. ABD: OPEN,BS ABSENT,S,TENDERNESS AT INCISION SITE. JP'S X2 TO LOW WALL SX FOR SM AMTS S/S DRAINAGE. NO BM.

GU: ANURIC. CVVH STATEED ATR APPROX 20:00. PT TOLERATED WELL. PRF: 260-380. GOAL TO KEEP PT EVEN. LYTES WNL.

ENDO: FS QID. COVERAGE PER HUMALOG SS. [**Hospital1 **] NPH.

INTEG: SKIN WDI. R-LATERAL PORTION HAND BLACK SCAB-OPEN TO AIR.

IVL'S: R-DIA CATH AND L-TRIPLE LUMEN CVL SITES WNL AND DRESSINGS CDI.

PSYCH/SOCIAL: NO FAMILY CONTACT OVERNIGHT.

PLAN: MONITOR NEURO STATUS. FOLLOW HEMODYNAMICS. AGGRESSIVE PULM HYGIENE. OR TODAY TO CLOSE OPEN ABD. CONTINUE CVVH GOAL TO KEEP I+O EVEN. LABS Q 6. NEXT SET OF LABS DUE AT 0800 ON [**2170-2-15**].PAIN MANAGEMENT. AGGRESSIVE SKIN CARE REPOSITION Q 2. PROVIDE SUPPORTIVE CARE TO PT AND FAMILY.


Admission Date:  [**2149-3-25**]              Discharge Date:   [**2149-4-1**]

Date of Birth:  [**2074-4-26**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Clotted AV Graft
Hyperkalemia

Major Surgical or Invasive


Procedure:


[**2149-3-25**]: Right femoral temporary dialysis line placement
[**2149-3-26**]: IR LUE AVF thrombectomy c/b Radial
art occlusion s/p extraction of thrombus.


History of Present Illness:
74M well known to the transplant surgery service presents
with clotted AVG of the left upper extremity and hyperkalemia to
6.8.  According to patient he is unaware when graft lost it's
pulse and thrill, but today at HD it was noted to be
nonfunctioning.  He was unable to be dialyzed and referred to
[**Hospital1 18**] for thrombectomy.  However, in the preop holding area
patient preoperative labs were notable for K of 6.8.  HE was
given insulin 10 units iv and d50.  Attempts at placing an HD
line were unsuccessful he is currently awaiting IR placement of
temporary HD line.


Past Medical


History:


1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
.
2. CARDIAC


HISTORY:


-PERCUTANEOUS CORONARY INTERVENTIONS
(1) CAD s/p NSTEMI and stenting of the distal RCA, OM2 in [**2-/2147**]
complicated by GIB and paroxysmal atrial fibrillation
(2) s/p NSTEMI and unstable angina in [**2148-10-2**], cath showed
compelte occlusion of all three stents placed in [**2-/2147**], stent
placed in LCx
(3) s/p unstable angina, [**Year (4 digits) **] to LCx since LCx placed in [**9-/2148**]
had instent stenosis
.
3. OTHER PAST MEDICAL


HISTORY:


-Three vessel CAD: see above for details
-Perioperative (bowel resection) vasospasm requiring cardiac
cath with NTG
-Mild-moderate MR
[**Name13 (STitle) 37625**] EF: 45% with focal inferior-posterior wall motion
abnormalities
-ESRD on HD, Cr [**2-18**] at baseline
-Ischemic Colitis: s/p SMA thrombectomy, with [**Doctor Last Name 3379**] pouch
and end ileostomy. Also complicated by recent diversion colitis
in 2/[**2146**].
-Peripheral [**Year (4 digits) 1106**] disease s/p aortobifemoral bypass [**2131**]
-Raynauds
-Dementia
-Atrial fibrillation
-H/o perioperative CVA: no deficits
-Hyperlipidemia
-HTN
-H/o Achalasia s/p esophageal dilation
-H/o VRE infection
-Anemia
-[**2149-3-26**] IR LUE AVF thrombectomy c/b Radial
art occlusion with thrombus extraction .


Social


History:


Patient lives with his wife. [**Name (NI) **] outside help needed. Active at
baseline.
-Tobacco


history:


40 pack years, quit 11 years ago
-ETOH: None
-Illicit drugs: None


Family


History:


Comes from a family of 20 kids. Only 2 are still alive.
Significant history of cardiac disease in the family.

Physical


Exam:


VS: 56 139/58 18 O2 sat=98% RA
NAD, Answers all questions, easily arousable but sleepy
bradycardic
crackles L> R
Soft abdomen with ileostomy with gas and + Output, Nontender
Ext: WWP, no edema.  LUE with radial avf scar well healed with
LUE AVG without pulse or thrill. 1+ radial bilaterally

Pertinent Results:
[**2149-3-30**] 04:19AM BLOOD WBC-6.2 RBC-3.33* Hgb-10.3* Hct-30.4*
MCV-91 MCH-30.9 MCHC-33.9 RDW-16.8* Plt Ct-140*
[**2149-3-31**] 05:15AM BLOOD PT-17.2* PTT-74.6* INR(PT)-1.5*
[**2149-3-30**] 04:19AM BLOOD PT-14.8* PTT-57.3* INR(PT)-1.3*
[**2149-3-29**] 04:16AM BLOOD PT-13.8* PTT-49.0* INR(PT)-1.2*
[**2149-3-30**] 04:19AM BLOOD Glucose-95 UreaN-24* Creat-5.5*# Na-139
K-3.6 Cl-96 HCO3-33* AnGap-14
[**2149-3-30**] 04:19AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0

Brief Hospital Course:
74 y/o male admitted with non-functioning AV graft, found at HD.
On admission labs the potassium was 6.8. At this time an attempt
was made to place a temporary IJ line for emergent HD. Right IJ
was very small in caliber and left IJ was unable to be wired.
Procedure was stopped and the patient sent to IR to have femoral
line placed given past history of bilateral aorto-[**Hospital1 **] fems.
Hemodialysis was performed via that line with post HD potassium
of 4.3.

On [**2149-3-26**], he underwent IR LUE AVF thrombectomy c/b radial art
occlusion that requried consulting Dr. [**Last Name (STitle) **] who
performed  extraction of thrombus with export device. He was
treated w/ heparin, integrelin and TPA. Completion angiogram
demonstrated patent radial and ulnar arteries. However, the left
radial pulse was not palpable, but the ulnar was palpable.

On [**3-29**], hemodialysis was successfully performed via the left
arm AVG. On [**3-30**], the temporary right groin dialysis line was
removed. He did experience bleeding at this site requiring a
pressure dressing that was removed on [**3-31**]. No futher bleeding
occurred at groin site. He was dialyzed again on [**4-1**] without
incident via the left AVG.

He remained on a heparin drip until [**3-31**]. Coumadin (5mg) was
given on [**3-30**] and [**3-31**]. INR increased to 2.2 on [**4-1**].  After
furhter review, long term coumadin was stopped given h/o of GI
bleed 6months prior. He was to continue on aspirin and plavix
given h/o cardiac stents.

The left arm AVG had a thrill and was working well for dialysis
on [**4-1**]. Vital signs were notable for sbp in 160-190 range.
Amlodipine 5mg qd was started. He was tolerating food and ostomy
was functioning well. PT assessed him and declared him safe for
discharge to home. He will resume dialysis in [**Location (un) **].

Of note, PT recommended a rolling walker and home PT. This was
arranged prior to discharge.
.


Medications on Admission:
aspirin 325 mg Tablet, Plavix 75 mg, amiodarone 200 mg',
carvedilol 12.5 mg", lisinopril 7.5 mg', loperamide 2 mg ",
pantoprazole 40 mg', lovastatin 10 mg', sevelamer HCl 800 mg"',
1337 mg "', isosorbide mononitrate 30 mg', Nephrocaps 1 mg'.


Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. loperamide 2 mg Capsule Sig: One (1) Capsule PO Q 12H (Every
12 Hours).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a
day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever: no more than 4000mg per
day.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home with Service

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
ESRD
thrombosed AVG
left radial artery occlusion


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.

Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever, chills, Left arm swelling, discoloration, numbness,
increased pain or bleeding or you experience any bleeding from
right groin old catheter site
You can resume dialysis at [**Location (un) **]. Dr. [**Last Name (STitle) **] will manage your
Coumadin dosing


Followup Instructions:
[**Name6 (MD) 5536**] [**Name8 (MD) **], MD ([**Hospital **] Care Center) Phone:[**Telephone/Fax (1) 5537**]
Date/Time:[**2149-4-21**] 1:00



Completed by:[**2149-4-1**]


Respiratory Care Note
Baby remains on SIMV 24/6, RR 24, FiO2 21-27% this shift. BS coarse to clear with suctioning. Needing frequent suctioning for moderate amount of cloudy secretions each time. RR 50-60's, but occasionaly 70-80's. No spells noted. ABG:7.24/47/59/21/-7. No vent changes at this time.


Pt s/p lap chole
 extubated in OR and reintubated in PACU for poor
   ABGs.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name **])
   Assessment:
   Admitted to  SICU intubated on CMV with 7 PEEP and 5 PS.  Pt sleepy,
   but arousable.  Following all commands.
   Action:
   Initially tried to wean pt to CPAP without success.  Waited a few hours
   and weaned pt to MMV and then CPAP.
   Response:
   Plan:


Nursing Procedure Note
Rectal dilation done by [**Last Name (NamePattern4) 3664**], MD with 11, 12, minimal results of green stool noted.
Rectal irrigation done at bedside by [**Last Name (NamePattern4) 3664**], MD with 8.0fr catheter.  5.0cc NS intstilled.  With pressure infant stooled through 8.0fr catheter.
Surgery resident placed indwelling rectal catheter.
16fr cathider inserted a few inches into rectum (black dot marked at placement).  5.0cc NS inserted into cath.  Rectal catheter taped into place--needs to stay in for 3 hrs, draining to gravity.  Plan to pull at 1500, surgery to be in later tonight.


Atrial fibrillation with a rapid ventricular response.  Non-specific ST-T wave
changes.  Compared to the previous tracing the rate is slightly slower.
TRACING #2


[**2187-9-28**] 12:08 PM
 ABDOMEN (SUPINE ONLY) PORT                                      Clip # [**Clip Number (Radiology) 69768**]
 Reason: ? interval change, ? evidence of ileus/obstruction/free air
 Admitting Diagnosis: SEPTIC; SEIZURES
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


53 year old man with quadriplegia, recent RUQ abdominal fluid collection s/p
  percutaneous drainage, now with increasing abdominal pain


REASON FOR THIS EXAMINATION:


? interval change, ? evidence of ileus/obstruction/free air
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


53-year-old man with quadriplegia, recent right upper quadrant
 abdominal fluid collection status post percutaneous drainage, now with
 increasing abdominal pain, ? interval change or evidence of
 ileus/obstruction/free air.


COMPARISON:


CT scan of [**2187-9-21**].


FINDINGS:


AP supine images of abdomen and pelvis showed gas-filled loops of
 bowel, predominently colon, that extend to the rectosigmoid region. There are
 no clear signs to suggest obstruction. No definitive evidence of free air
 within limits of the supine images. Complete opacification of the visualized
 portion of the right lung base and nonvisualization of the left hemidiaphragm
 is compatible with right lower lobe collapse seen on the recent CT scan.  An
 NG tube projects over the stomach.


IMPRESSION:


Bowel gas pattern is nonspecific and nonobstructive.


Respiratory Care:
pt remains on vent. as per CareVue. event of today was to [**Month (only) **] ps to 12cms. See CareVue for detail.
Plan is to continue slo wean.


[**2146-3-24**] 9:04 AM
 CT ABD W&W/O C; CT PELVIS W&W/O C                               Clip # [**Clip Number (Radiology) 44223**]
 CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION
 Reason: 1020
 Field of view: 38 Contrast: OPTIRAY Amt: 150
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


64 year old man with


REASON FOR THIS EXAMINATION:


HEMATURIA
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


CLINICAL INDICATION:


64-year-old male with a history of bladder cancer and
 hematuria.


TECHNIQUE:


Contiguous axial images were obtained from the hemidiaphragms
 through the pubic symphysis prior to and following the administration of
 150 cc of Optiray. Coronal reformatted images were included.


COMPARISON:


[**2145-2-25**].

 CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The visualized lung bases are
 clear. There are no pleural effusions. The liver, gallbladder, spleen,
 pancreas, and adrenal glands appear grossly normal. There is a hypodense
 exophytic nodule arising from the left kidney which is too small to
 characterize. This finding is concerning for disease recurrence. An internal
 examination via cystography is recommended.

 BONE WINDOWS: A dense calcific density is again evident within the left iliac
 bone, likely representing a bone island. No suspicious lytic or blastic
 lesions are identified.


IMPRESSION:


Irregularity of the neobladder neck wall concerning for disease
 recurrence. Internal examination is recommended.


SOCIAL WORK NOTE:
Pt (more specifically, his wife, [**Doctor First Name 1546**] known to this SW from his stay on CTIC/SICU.  I am covering the CCU for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] this week so I remain involved in pt's care.  [**Name (NI) 25**] wife has decided for withdrawal of care this afternoon because she states that it is in keeping with pt's wishes.  She was clearly able to state that pt "would not want this".  Pt's children and other family members are here with wife.  This SW met with them briefly to offer support and they are currently awaiting pt's extubation.  Will remain involved as needed.  Pager [**Numeric Identifier 299**].


Nursing 7p-7a
Neuro: Sedated on prop gtt. Arouses to voice. Follows commands. PERRLA. No apparent pain per grimace scale.

C/V: NSR 70s. No ectopy. SBP 90-130s. Accepting maps >60 [**Name8 (MD) 9**] MD [**Last Name (Titles) 896**]. Hct from previous shift 24.9. Received 2 prbcs, f/u 29.5. +PP. Bilat fingertips cool & dusky, R>L. Improved w/warm packs & blankets.

Resp: CMV. No vent changes overnoc. Sat >97%. Lungs clear, dim in LLL. CT x4 to SX . See carevue for drainage. Two on L side w/+ air leak- team aware. Suctioned for sm amts thick yellow. Copious oral secretions.

ID: Urine & blood cxs sent. Tmax 101.2. PO tylenol x1. IV vanco & zosyn. WBC decreased to 12.3.

Gi: NPO except meds via dophoff. TPN infusing. Hypo bs. No stool. Abd soft.
Gu: Adequate HUO. Creat 1.2.
Endo: RISS
Social: No call/visit from family.

Plan: ?Family meeting regarding POC, code status. TPN order. Pulm toilet. Monitor hemodynamics. F/U w/cultures.


Continuation
5.  PARENTING  O: Stressed to her that the best place for
her babies is with her and our goal is for the babies to
thrive well. A:  Concerned parent, needing assurance and
support to deal with frustrations  P:  Support and keep
updated.  Encourage to voice concerns and questions.  When
visiting, encourage to participate in care of infants.


TODAY
S EVENTS:  Rpt head CT- per neuro-med- further embolic stroke.
                                      Commenced on Heparin drip @  no
   bolus dose - 800units/hr @ 1630hrs - PTT due @ 2230hrs.
                                      Goal PTT 40-60.
                                      Vent weaned.
   Cardiac dysrhythmia other
   Assessment:
   Action:
   Response:
   Plan:
   CVA (Stroke, Cerebral infarction), Ischemic
   Assessment:
   Action:
   Response:
   Plan:
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 2**])
   Assessment:
   Action:
   Response:
   Plan:


RESPIRATORY CARE: PT EXTUBATED AFTER SUCCESSFUL SBT
AND AN RSBI OF 70. REINTUBATED 2 HOURS LATER FOR
TACHYPNEA/LABORED BREATHING AND HYPERCARBIC RESPIRATORY
FAILURE. 7.0 ORAL ETT IN PLACE AND PLACED ON AC MODE
AS PER CAREVUE. ABG PENDING.


NPN 1900-0700
Please see carevue for specific vs/data

NEURO: Neuro exam remains unchanged. R pupil 4mm/L pupil 3mm-both NR, corneals absent. No gag/cough still impaired. Only noted movement is pt's head, which moves side to side slightly with any facial stimulation (no withdrawal to noxious stimuli) Dilantin ordred Q8-am level pending. fentanyl gtt continues at 150mcg/hr-bolused during turns, as pt becomes hyperdynamic with stimuli.

CV: HR 80's-low 100's, no ectopy. A-line tracing dampened for much of night, blood draws becoming increasingly difficult to obtain (team aware)-will most likely require re-wiring later this am. Post transfusion
25.2 down to 24.7 this am-most likely dilutional. R pedal pulse difficult to palpate but present/L PPs easily palpable, cap refill <3sec.  +Generalized edema/anasarca.

RESP:No vent changes overnight. CPAP [**11-18**] on 50%. Mod amt thick yellow secretions sxnd from ETT, reponds well to chest PT.  Morning ABG showing adequate oxygenation, Co2 trending up slightly. Old CT site-occlusive DSD with sm amt old bloody drainage-no crepidus.VAP per protocol.

GI: Abd soft and obese, BS+. Replete with fiber at goal through OGT with min. residuals. No stool overnoc.

GU:Foley patently draining [**Location (un) **] urine with sm amt sediment at approx 60cc/hr. NS KVO. Remains +27L for LOS.

ID: Febrile for much of morning, t-max 100.6 (down to 99 on eves), tylenol provided along with ice bath/cold towels and fan. WBC trending down to 25 (30). Zosyn as ordered. Cxs pending.

ENDO: Insulin gtt at 5.5units/hr for much of night [**First Name8 (NamePattern2) **] [**Last Name (un) 167**] scale. Off protocol for a few hrs-glucose remaining stable though. ? change to NPH/ reg insulin sliding scale.

SKIN: All wound dsgs changed this am. R sie of head-degloving injury draining sm amt serosang. drainage, xeroform/DSD covering. L side of head-staples OTA-no drainage. Lac to L hand draining mod amt serous drainage-abd covering. Abrasions to L torso, shoulder, adn R hand OTA. Abrasion to LLE with abd pad-still draining sm amt sersang. drainage. Midline abd staples OTA-no erythema. Wound vac dsg to RLE at 125mmHg cont. sxn-drainage slowing down drom yesterday-now mostly serous. Upper lateral RLE incisuon site-staples intact, no drainage-DSD in place. Diabetic ulcers to R foot with aquacel. Sm blisters to coccyx intact. Skin at pressure sites and in between skin folds intact. Bari air big turn bed set turn pt side to side Q 15min.

SOCIAL: Visitor whom was a friend of pt's mother into visit last night (Ok to do so by pt's aunt)briefly. No calls from family overnight. [**Name6 (MD) **] [**Name8 (MD) **] RN one of pt's cousins may or may not be able to travel to say goodbye to pt and instead may call to do so. Plan for family meeting today to discuss withdrawal of care and ? organ donation. Per police case is being ruled as a homicide and pt will require an autopsy.

34 y.o male s/p ped struck with multiple injuries including SAH with infarcts (as a result of cardiac arrests in ED) Pt s/p ORIF RLE, fasciotomy with wound vac placement,and spl


CVICU
   HPI:
   HD11   POD 9-s/p ascending aorta replacement resuspension AVR
   Ejection Fraction:55%
   Pre-Op Weight:242.5 lbs   110 kgs
   Baseline Creatinine:4 (acute)
   Foley:Day10
   PMHx: HTN, s/p T+A
   [**Last Name (un) **]: HCTZ ? dose
   Events:
   [**2187-8-21**] RAF->Dilt gtt/Amio bolus/^po dose of Amio/Lopr./start po
   Dilt->SR.No OR-bumpd
   [**2187-8-20**] afib received extra BB, HD for ^BUN/Cr, transplant consulted
   for tunnel line
   [**2187-8-19**] bun/cr increasing, fluid balance negative
   [**2187-8-18**] extubated, Afib no coumadin per RH ^ BUN/Cr
   [**2187-8-17**] head ct neg, sternal drainage, propofol q4h neuro checks,
   transfuse 2 units
   [**2186-8-14**] hypoxia ^ PEEP, Afib tx w/ BB and amiodarone, converted to SR
   Assessment:61 year old male Repair of type A aortic dissection - 28-mm
   Dacron interposition tube graft from the sinotubular junction >
   proximal arch using deep hypothermic circulatory arrest
   Plan:tunnel line wednesday with transplant
   Chief complaint:
   PMHx:
   Current medications:
   24 Hour Events:
   [**8-22**]: RAF converted with to NSR 60s. No anticoagulation at this time per


MICU NURSING NOTES :

PLEASE SEE CAREVUE FOR ADM DETAILS & OBJECTIVE DATA.

EVENTS :
LEVOPHED TITRATED TO ACHIEVE GOAL MAP > 60. A-LINE INSERTED AFTER MULTIPLE ATTEMPTS. NS 500 MLS BOLUSES X 3 FOR BP. FOLEY INSERTED DRAINED OUT 30 MLS, ANURIC.

NEURO : LETHARGIC AT THE BEGINING OF THE SHIFT, MORE ALERT TOWARDS MORNING, ORIENTED X 3, CALM COOPERATIVE WITH CARE. SLOW TO ANSWER AT TIMES. DENIES PAIN.

RESP : CONTINUED ON NC 4 LITS, LS CLEAR DIMINISHED AT BASES. SPO2 IN 90'S.

CVS : A-PACED, OCCASIONAL PAC'S, PVC'S. S-ABP 80'S TO 130'S, MAPS 50'S TO 80'S. FEMORAL CENTRAL LINE, CVP IN 30'S. LEVOPHED TITRATED & WEANED DOWN TOWARDS AM. PLAN TO DC LEVO GTT. NS BOLUSED AS MENTIONED ABOVE.

GI: ABD SOFT, DISTENDED. BS PRESENT, NO BM.NPO. ICE CHIPS ALLOWED.

GU : FOLEY INSERTED AS [**Name8 (MD) 21**] MD SUMMERS ORDERS, PT ANURIC. PLAN FOR DIALYSIS TODAY. HD CATH TO BE INSERTED.

ID : HYPOTHERMIC, BAIR HUGGER FOR SOMETIME WITH SOME EFFECT. WBC 70. CONTINUED ON VANCO/ LEVOFLOX/ ZOSYN.

SOCIAL : DAUGHTERS IN TO VISIT. MD SPOKE TO PATIENT & FAMILY.

PLAN :
MONITOR BP.
MONITOR TEMP CURVE, follow up on cultures, continue antibiotics.
NEPHRO CONSULT FOR DIALYSIS.
EMOTIONAL SUPPORT TO PATIENT & FAMILY.


88M nursing home resident who has had abd pain for 2 days.  Abdominal
   film showed concern for ileus vs SBO.  He began vomiting [**9-19**] and was
   brought to the ED.  He was alert and orientated, but unable to give a
   good history.  Family members have reversed his DNR status.  CT abdomen
   demonstrated closed loop obstruction.   Pt went to the OR s/p  ex lap,
   lysis of adhesions/ SBR approximately 6 inches.  EBL 700, received 3l
   lr and 750 albumin. Low u/o 120cc and pt was neo dependent during the
   case.  Arrived paralyzed and sedated, intubated and on neo.
   PMHx:
   Type 2 Diabetes Mellitus
   Chronic Renal Insufficiency
   Sick Sinus Syndrome s/p pacemaker with underlying rhythm afib
   Vtach s/p AICD
   Severe Cardiomyopathy EF 10-15%
   CAD
   AAA (3.4 cm)
   Small bowel obstruction (Intestinal obstruction, SBO, including
   intussusception, adhesions)
   Assessment:
   Alert when sedation weaned, but does follow commands, moves all
   extremities. Lung sounds clear, scant secretions orally and in ETT.
   Intubated on CPAP with PS 5/5 40% with improved ABGs. Vigeleo
   monitoring. Bowel sounds present, but hypoactive, no flatus.
   Action:
   Gastric tube to gravity drain, Jtube clamped, NGT to low wall suction.
   Lytes repleted as needed, frequent turning and aggressive pulmonary
   toileting. Vigeleo monitored. CVP monitored.
   Response:
   Output in gtube is bilious and dark. Urine output >20 ml/hr, moderate
   edema to seen at scrotum and bilateral upper extremities. Scant
   secretions seen in ETT and orally. Alert when lightened but does not
   follow commands. Neo and Levo and Metoprolol not needed.
   Plan:
   Continue to wean to extubate, consider Bipap after extubation, to
   discuss with team during rounds, consider Albumin and Lasix if needed.
   HCTs >26.


Sinus rhythm. Non-diagnostic Q waves in the inferior nleads Non-specific
anterolateral ST-T wave changes. Compared to the previous tracing no
significant change.


NPN 0700-1500


#1 O: Received infant on prong CPAP of 6cm where he
presently remains. FIO2 35-42%. LS clear and =. RR 50's-70's
with mild SC retractions. No spells; does drift in his o2
sats occasionally. A: Stable on CPAP. P: Cont to monitor.

#3 O: TF increased to 140cc/kg/d. Infant receiving TPN D10
with IL via PIV at 110cc/kg/d. Enteral feeds are at
30cc/kg/d or 10cc's q 4h via gavage. Abdomen benign; voiding
1.7cc/kg/h, no stools this shift. No spits or aspirates. A:
Tolerating feeds so far. P: Plan to increase by 10cc/kg [**Hospital1 **]
at 1300 and 0100 as tolerated.

#4 O: Maintaining temp in heated isolette set in servo mode.
Awake and alert with cares; very irritable bwteen, not able
to be consoled at times. Nested in sheepskin with tight
boundaries in place. Sucks on pacifier when offered. NAS
[**Doctor Last Name 665**] 9,10 today. Phenobarb and morphine given as ordered.
Phenobarb to be changed to q 12h starting tomorrow. Morphine
given q 4h. Aquaphor applied to excoriated armpit. HUS next
week. A: Irritable infant; withdrawing. P: Cont to support
development.

#5 O: Mom in briefly with her father. Stated she is having a
difficult time choosing names for the babies as there are so
many and she's not sure who they look like. Updated at
bedside. A: SW Involved. P: Cont to support and update.


Chief Complaint:
   24 Hour Events:
   [**2145-4-27**]
   - Increased WBC with 1 band
   - Octreotide discontinued
   - Started SQ heparin
   - Per Hep: appears worse with leukocytosis -> broadened abx from cipro
   to vanc/zosyn. Sisters/HCP refusing paracentesis at this time. Spoke to
   Hep fellow and attg regarding this. Plan for family mtg around 1-2pm
   tomorrow.
   - Goal I/O net neg on CVVH but limited by BP. Levophed uptitrated;
   given fluid back via CVVH. Given 1 unit pRBC for volume expansion as
   Hct 22. Started on vasopressin. Able to wean off some levophed.
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Ciprofloxacin - [**2145-4-26**] 10:02 PM
   Vancomycin - [**2145-4-27**] 04:00 PM
   Piperacillin/Tazobactam (Zosyn) - [**2145-4-28**] 04:28 AM
   Infusions:
   Calcium Gluconate (CRRT) - 2.1 grams/hour
   Vasopressin - 1.2 units/hour
   KCl (CRRT) - 2 mEq./hour
   Norepinephrine - 0.2 mcg/Kg/min
   Other ICU medications:
   Pantoprazole (Protonix) - [**2145-4-27**] 08:00 PM
   Heparin Sodium (Prophylaxis) - [**2145-4-27**] 10:16 PM
   Other medications:
   Changes to medical and family


history:


Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2145-4-28**] 06:34 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 36.8
C (98.2
   Tcurrent: 36.1
C (97
   HR: 102 (89 - 115) bpm
   BP: 78/48(58) {72/43(53) - 101/56(69)} mmHg
   RR: 12 (11 - 28) insp/min
   SpO2: 97%
   Heart rhythm: ST (Sinus Tachycardia)
   Height: 73 Inch
           Total In:
                                                                  8,605 mL
                                                                  3,180 mL
   PO:
           TF:
                                                                    877 mL
                                                                    295 mL
   IVF:
                                                                  6,992 mL
                                                                  2,212 mL
   Blood products:
   553 mL
   Total out:
                                                                  7,859 mL
                                                                  1,682 mL
   Urine:
   NG:
   Stool:


Baseline artifact.  Atrial fibrillation with occasional ventricular premature
beats.  Complete right bundle-branch block.  Non-specific ST-T wave change with
QTc interval at the upper limits of normal.  Compared to the previous tracing
of [**2113-4-21**] no diagnostic change.


Sinus tachycardia. No previous tracing available for comparison.


Neonatology-[** 1**] Physical Exam

[**Known lastname 4103**] remains in NC.   Active, alert in an open crib, AFOF, sutures opposed, good tone.  BBS clear and equal with good air entry, mild SC retractions.  No murmur, pulses +2, pink,/pale, RRR.  Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds.  Please refer to attending progress note for detailed plan.


Neonatology
Doing well. Remains on CPAP. To trial off today. COmfortable appearing.

Wt 1485 down 15. Tolerating feeds at 140 cc/k/d of 28 cal. Abdomen benign.

Eye exam to be repeated in am.

COntinue as at present. REassess for need to return to CPAp.


Respiratory Care
Baby [**Known lastname 3655**] remains on HIFI MAP of 10, AMP of 12. Fio2 today has ranged from 21-29%, but has remained at 21% since 1100 today. Baby was turned at 0930, bagged at pressures of 22/5, breath sounds are coarse, suctioned small cloudy from ETT, small clear oral. No spells as of this time, is receiving fentanyl, got transfused. ABG today of 7.26/51/53/24/-4, no changes made. Continue to monitor.


79F s/p MVC on [**8-14**] restrained passenger, prolonged extrication, +LOC,
   obvious flail chest, intubation for respiratory difficulty.
   Chief complaint:
   (1) Multiple bilateral rib frx with sternal frx
   (2) C2 R transverse process frx
   (3) Splenic rupture s/p spleenectomy
   (4) R distal radius frx
   (5) L basal index finger frx
   (6) dislocated 1st R metatarsal
   (7) L elbow dislocation
   (8) G-tube perforation s/p ex lap, primary closure
   (9) ATN following abd compartment syndrome
   (10) Gram negative sepsis
   [**9-18**] - Chest CT to evaluate size of pleural effusion, ?infiltrate
   Alteration in Nutrition
   Assessment:
   Pt. on goal TF 70cc/hr via [**Doctor Last Name **] tube, unable to place Dophoff @
   bedside.
   Action:
   NGT placed post-pyloric via fluoroscopy, [**Doctor Last Name **] tube remains in place
   Response:
   [**Doctor Last Name **] tube clamped, TF started @ 10ml/hr via NGT.
   Plan:
   Increase TF as tolerated, monitor JP drain output
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 2**])
   Assessment:
   Pt. placed on CPAP/PS this am, pt. c/o difficulty breathing despite RR
   in 20
s and Os sats>95%
   Action:
   Pt. given recruitment breaths for consolidation on morning x-ray
   Response:
   Pt. continues to sat >95%, RR occasionally >30 with anxiety, Ativan
   given PRN
   Plan:
   Continue CPAP/PS as tolerated, PRN anxiety, PRN recruitment breaths
   Pain control (acute pain, chronic pain)
   Assessment:
   Pt. grimacing with turns, c/o hip and back pain
   Action:
   Pt. repositioned frequently, OOB to chair, ice applied to hip, PRN
   Dilaudid and Roxicet
   Response:
   Pt. resting this afternoon, no c/o pain
   Plan:
   Continue PRN narcotics, repo frequently, apply ice PRN


[**2106-12-7**] 9:06 PM
 MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST                    Clip # [**Clip Number (Radiology) 19211**]
 Reason: eval for CVA, please perform stroke protcol
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


74 year old woman with hand clumbsiness and sensation changes


REASON FOR THIS EXAMINATION:


eval for CVA, please perform stroke protcol
 ______________________________________________________________________________
 WET READ: MNIa TUE [**2106-12-7**] 11:23 PM
  NO AREAS OF SLOW DIFFUSION. T2 HYPERINTENSE AREA IN THE LEFT OCCIPITAL LOBE
  CORRESPONDING TO LOW DENSITY ON CT ON 6/[**2105**]. (THERE ARE SLIGHT HIGH SIGNAL
  ALONG THE CORTEX ON DWI, HOWEVER, THEY ARE OFTEN BILATERAL AND SOME OF THE
  MARE SEEN ON THE PRIOR STUDIES, AND ARE THOGHT TO BE TECHNICHAL. ).MULTIPLE
  NON-SPECIFIC HYPERINTENSE FOCI IN THE CEREBRAL WHITE MATTER SOME OF WHICH
  REPRESENT DILATED PERIVASCULAR SPACE UNCHANGED SINCE PRIOR STUDY. NO FLOW
  LIMITING STENOSIS. SYRINX SEEN IN THE CERVICA CORD, AS WAS NOTED ON [**2102**].
  EVALUAITON BY CERVICAL MRI CAN BE PERFORMED FOR FURTHER EVALUATION IF
  CLINICALLY INDICATED. WET READ TO CCC. [**Doctor Last Name **] M. 11:20 pm.
 ______________________________________________________________________________


FINAL REPORT


MRI AND MRA OF THE BRAIN DATED [**2106-12-7**]


HISTORY:


74-year-old woman with hand clumsiness and sensory changes; evaluate
 for CVA.


TECHNIQUE:


Routine [**Hospital1 14**] non-contrast MRI and MRA of the brain was performed.


FINDINGS:


The study is compared with most recent NECT dated [**6-11**], as well as
 MRI and MRA of the brain, dated [**2106-4-10**]; the overall appearance of the brain
 is unchanged. There is relatively mild cortical atrophy and evidence of
 chronic microvascular ischemia, is unchanged. There are prominent Virchow-
 [**Doctor First Name 1601**] spaces in bilateral centra semiovale with a chronic-appearing lacune on
 the left, not clearly demonstrated previously. There is a 1.5 cm (TRV)
 triangular focus of CSF- signal intensity involving the superficial aspect of
 the left occipital pole. This was not present on the [**2106-4-10**] study, but was
 evident on the [**2106-6-11**] CT and likely represents interval infarction in this
 region.  There is no focus of decreased diffusion to indicate acute
 infarction.  There is no intra- or extra-axial hemorrhage, the midline
 structures are in the midline and the ventricles and cisterns are unchanged in
 size and in contour.  The major intracranial vascular flow voids are preserved
 (see MRA below).  Incidentally noted are moderate mucosal thickening involving
 several anterior ethmoidal air cells, bilaterally.  Again demonstrated is a
 syrinx within the included portion of the upper cervical spinal cord,
 commencing roughly the level of the base of the dens.  This finding has not
 substantially changed since the brain MR dated [**2099-8-13**], and there are no
 dedicated studies of the cervical spine on record.

 The MRA sequence is substantially degraded by excessive patient motion
 artifact.  Allowing for this, there is normal flow-related enhancement in the
 included intracranial portions of both internal carotid and proximal anterior
 middle cerebral arteries, with normal, symmetric arborization of MCA branches
 and no flow-limiting stenosis.  There is normal flow-related enhancement and
                                                             (Over)

 [**2106-12-7**] 9:06 PM
 MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST                    Clip # [**Clip Number (Radiology) 19211**]
 Reason: eval for CVA, please perform stroke protcol
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 roughly codominant distal vertebral arteries and the basilar and bilateral
 superior cerebellar and posterior cerebral arteries with no flow-limiting
 stenosis or aneurysm.  Note that there is a fetal origin of the right PCA and
 probable fetal-equivalent left PCA as that PCom vessel is quite large, whereas
 the short left P1 segment is very small in caliber.


IMPRESSION:


1.  No acute intracranial abnormality.

 2.  Evidence of small focal encephalomalacia involving the left occipital
 pole, more likely representing old infarct, as well as chronic-appearing
 lacune in the left centrum semiovale.  There is no evidence of acute
 infarction.

 3.  No hemorrhage.

 4.  Limited but unremarkable cranial MRA, with no flow limiting stenosis and
 essential fetal origin of both PCAs.


MICU NPN 2200-0700:

PT. RECEIVED AS TRANSFER FROM VICU FOR HYPERCAPNEA/RESP. FAILURE FOR BIPAP & AGGRESSIVE PULMONARY TOILET.                                                                                                     RESP: INITIAL ABG 7.18/70/150. PLACED ON BIPAP 10/10, 40% & TOLERATES WELL WITH ABG 1 HOUR AFTER 7.31/47/177/25. RESTED ON BIPAP UNITL 0500 & PLACED ON 3L NC WITH ABG TO FOLLOW & MOST RECENT 7.35/48/151. RECEIVED CHEST PT & NT SUCTION FOR SMALL THICK TAN SECRETIONS PRIOR TO ABG. TOLERATES WELL. CONTINUE 3L NC AS TOLERATES. REPEAT ABG AS ORDERED. COARSE BREATH SOUNDS.

NEURO: CONFUSED TO TIME & PLACE. IRRITABLE & ANXIOUS AT TIMES. INTERMITTENT AGGRESSIVE BEHAVIOR NOTED. PERIODS OF ATTEMPTING TO KICK & HIT AT STAFF. BILATERAL SOFT WRIST RESTRAINTS INTACT TO MAINTAIN TREATMENT & FOR SAFETY. MAE X4. STRONG COUGH, WEAK GAG. DOES FOLLOW COMMANDS.

CV: ON ARRIVAL SBP 70'S, CVP FROM 10 TO 4. RECEIVED 3 NS FLUID BOLUSES 250 CC WHICH RESPONDED TO WELL. DID RECIVE IU PC FOLLOWED BY LASIX 40 MG IV WITH MARKED DIURESIS PRIOR TO TRANSFER.  BP IS LABILE 90-150/50-60'S. CLONIDINE PATCH, HYDRALAZINE, NTG TOP ALL HELD PER ORDER THIS SHIFT FOR SBP < 180 & TO BE REEVALUATED BY TEAM THIS AM. RIJ TLC WITH TPN & NS @ KVO. RIGHT RADIAL ARTERIAL LINE. SITES INTACT & CLEAR. MONITOR NSR 70-90 WITH OCCASIONAL BRADYCARDIA 30'S LASTING < 3 SECONDS. BEING FOLLOWED BY CARDIOLOGY FOR POSSIBLE INSERTION OF PPP. CVP 8-11 FOLLOWING IVF BOLUS & BP HAS BEEN STABLE. DENIES PAIN OR DISCOMFORT. SERIAL CPK'S Q 8 HRS, NEG X2. EKG X2 DONE NO ACUTE CHANGES. LAST CPK TO BE DRAWN @ 1400.

GI: NPO. NG TO LCWS WITH SMALL BILIOUS DRAINAGE. HYPOACTIVE BS. NO BM. MEDS TO BE GIVEN VIA NG.  FREQUENT ORAL CARE GIVEN. STRICT ASPIRATION PRECAUTIONS. 1 U PRBC YESTERDAY FOR HCT 27. RECHECK THIS AM IS 31.5.

ENDO: Q 6 HR FINGERSTICK WITH SS INSULIN COVERAGE. LAST RESULT 94.

GU: FOLEY CATH WITH ADEQUATE URINE OUTPUT > 30 CC/HR.

INTEG: BILATERAL GROINS & ABDOMEN WITH STAPLES INTACT. ALL INCISIONS WELL APPROXIMATED OPEN TO AIR WITH NO DRAINAGE NOTED.

ID: AFEBRILE. WBC 10. CEFTRIAXONE FOR PRESUMED GM NEG RODS IN SPUTUM. BC X2 & URINE C&S OBTAINED & SENT.

FL/ELEC: MG 1.9 & REPLACED. THIA AM MG 2.4, K 4.4.

SOC: SON SPOKE WITH MD PRIOR TO TRANSFER & IS SUPPORTIVE.

PLAN: CONTINUE CHEST PT & AGGRESSIVE PULMONARY TOILET. FREQUENT ABG'S AS NEEDED. GIVE SUPPORT. PT. IS FULL CODE IN MICU.


Respiratory failure, acute (not ARDS/[**Doctor Last Name 76**])
   Assessment:
    No vent settings  changes made this shift, current settings  AC/
   400/12/5/40%. LS  diminished . ET secretions  small to moderate thick
   white . Impaired gag & cough. Failed  with PS yesterday.responding to
   call   sometimes,response well to pain
   Action:
   Maintained on VAP  precautions,  suctioned prn. Off sedation.
   Response:
   Remains same. Team spoke with daughter [**Name (NI) **] over the phone .daughter
   agreed for  tracheostomy today.
   Plan:
   Plan for tracheostomy  today, feed stopped at MN ,heparin stop at 6am
   Impaired Skin Integrity
   Assessment:
   Pt continues to have  mild  drug rash  on back, torso and extremities,
    improving. Has generalised edema, dry skin ,  third spacing from her
   upper & lower extremities.
   Action:
   Skin care given and Frequent  change of position ,bath given and body
   lotion applied. Extremities wrapped with abd pad.
   Response:


SICU
   HPI:
   HPI:88F with multiple medical problems, now with
   tachypnea/desaturation/mental status changes requring BIPAP in
   ED(without intubation as pt is DNR/DNI), Found to have a sigmoid
   volvulus requring scope  to decompress. After arrival in TICU follwing
   scope decompression,  decision made for comfort measures only.
   .
   ISSUES:
   Sigmoid Volvulus
   Respiratory failure
   .
   CURRENT MEDICATIONS:
   .
   EVENTS:
   .
   24 HOUR EVENTS:
   .
   SURGICAL Hx:hysterectomy many yrs ago
   .
   SOCIAL Hx: no tobacco, son is HCP, at baseline lives at [**Name (NI) 4923**]
   [**Hospital3 **], uses walker, and new O2 requirement since last
   inpatient hospitalization (discharged [**12-21**])
   .
   ALLERGIES: NKDA
   .
   EKG:
   .
   ABX: None
   .
   MICRO: None
   .
   IMAGING: CT [**Last Name (un) 61**] [**2160-12-26**]: Partial large bowel obstruction, with an
   organoaxial volvulus seen at the junction of the descending and sigmoid
   colon. No small bowel dilatation. Retention of oral contrast in the
   cecum extending to the point of the volvulus. Small amount of contrast
   passage beyond the transition point. Moderate cardiomegaly with
   chronically collapsed left lower lobe and mild right-sided pleural
   effusion.
   .
   ASSESSMENT AND PLAN:
   88F (DNR/DNI) s/p rigid sigmoidoscopy for decompression of sigmoid
   volvulus, decision made for comfort measures only.
   All medications and infusions stopped, BIPAP withdrawn, Morphine
   infusion for comfort.
   Chief complaint:
   CHIEF COMPLAINT: Sigmoid volvulus
   PMHx:
   MEDICAL:DM2, Afib on coumadin, JHTN, dyslipidemia, PVD, sick sinus
   syndrome s/p pacer, glaucoma, skin CA
   Current medications:
   [**Last Name (un) **]: coumadin 2 qday, glipizide 5 qday, senna 1 tab [**Hospital1 **], colace
   100 [**Hospital1 **], brimonide 0.15 % drops [**Hospital1 **], pantoprazole 40 qday,
   tylenol prn, MVI 1 tab qday, lisinopril 20 qday, atenolol 25
   qday, lasix 40 po bid, dulcolax 10 po qday, Insulin SS, Potassium
   Chloride 40 meq [**Hospital1 **] while on lasix
   24 Hour Events:
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Infusions:
   Morphine Sulfate - 2 mg/hour
   Other ICU medications:
   Fentanyl - [**2160-12-26**] 01:14 PM
   Insulin - Regular - [**2160-12-26**] 02:43 PM
   Other medications:
   Flowsheet Data as of  [**2160-12-26**] 10:11 PM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**63**] a.m.
   Tmax: 35.2
C (95.4
   T current: 35.2
C (95.4
   HR: 104 (69 - 104) bpm
   BP: 86/41(56) {64/27(39) - 110/59(78)} mmHg
   RR: 32 (14 - 34) insp/min
   SPO2: 81%
   Heart rhythm: AF (Atrial Fibrillation)
             Total In:
             2,370 mL
   PO:
             Tube feeding:
   IV Fluid:
   2,370 mL
   Blood products:
   Total out:
                                                                      0 mL
                                                                    350 mL
   Urine:
   350 mL
   NG:
   Stool:


Respiratory Therapy
Pt transfered to CCU intubated s/p cardiac arrest on floor. Remains on full ventilatory support. RSBI 34. PMH: bilateral CVA. Code status being reevaluated by family.


Tracheobronchial Disease, Other (Trachea / Bronchus, including injury)
   Assessment:
   -pt. violently coughing with movements and stimulation
   Action:
   -Bronch this am to assess placement of [**Last Name (un) **]
   Response:
   -[**Last Name (un) 2523**] advanced in hopes to decrease coughing episodes
   -During bronch and coughing episode, pt. expelling mucous from nose
   -NGT d
cd d/t possibility of sinusitis, nasal aspirate sent for cx.
   -Sedation weaned slightly today
   Plan:
   -Monitor resp. staus, wean sedation as tolerated
   -Awating cx. Results
   -Place OGT for feeds
   Plan for stent in SVC on Monday


