79 yo with pmh significant for CHF (EF 20%), AF, COPD, CAD and dementia who presented with septic shock and acute cholecystitis->G-bldr drain placed in IR on [**6-9**].

NEURO: Alert and oriented x3, pleasant and [**Month/Year (2) **] with care. +mae noted. cough/gag intact. +PERRLA noted (L pupil not midline). c/o abd discomfort in am which resolved spontaneously, currently denies pain or discomfort.
CV: Monitor shows V-paced rhythym with transient episode of A-flutter. BP tenuous with position change->NS 250 cc bolus given x1 with improvement. Remains off pressors. Pulses via doppler.
RESP: LS coarse throughout with diffuse wheezes and bibasilar crackles noted. Remains on RA. Denies SOB or resp distress. Started on Advair this shift in addition to Albuterol/Atrovent nebs q6hr by RT.
GI: Abd soft and distended. +BS noted. Inc liquid brown stool x4 (heme -). Mushroom catheter inserted. Remains NPO x meds.
GU: Foley intact and patent draining sm amts yellow urine with no sedimentation noted, ~10-35 cc/hr.
SKIN: Coccyx pink and intact, protective barrier cream applied. G bldr drain exit site with sm amt bloody drainage at exit site, wash with 1/2 st hydrogen peroxide and DSD applied, irrigated with 10 cc's sterile saline @ 0800 and 1600.
I-D: Bld cx's with GNR. GB fluid iwth GNR. Started on Cipro in addition to Zosyn. Flagyl d/c'd. Bld cx's x2 sent (venipuncture and PIV). Afebrile. WBC 19 (14.9).
Heme: Repeat Hct 27.2 (25.2). Mag repleted as ordered.
Access: PIV x3
Psy-Soc: Nephew visited this am, updated on status and plan of care by this RN. Code status DNR.
Plan: Monitor BP and UO, tx with IVF's and pressors if needed. Monitor resp status, would use bipap for decompensation. Monitor Hct. ? advance diet in am. Plan for PICC or midline in future once blc cx's negative. Cont to assess for pain. Cont to cycle cardiac enzymes (new T wave inversion likely in setting of ^'d demand). Update pt/family on statur and plan of care. ? c/o to floor in am.


Sinus rhythm
Marked left axis deviation - left anterior fascicular block
Intraventricular conduction defect
LVH with secondary ST-T changes
ST-T wave changes - also consider ischemia
Since previous tracing, no significant change


[**2170-11-29**] 1:17 PM
 SCROTAL U.S.                                                    Clip # [**Clip Number (Radiology) 50246**]
 Reason: eval for epididymitis/orchitis
 Admitting Diagnosis: CONGESTIVE HEART FAILURE;RULE OUT CORONARY ARTERY DISEASE;ATRIAL FIBRILLATION\CATH
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


80 year old man with CAD, CHF, swollen tender erythematous scrotum b/l and UTI


REASON FOR THIS EXAMINATION:


eval for epididymitis/orchitis
 ______________________________________________________________________________


FINAL REPORT


STUDY:  Scrotal ultrasound.


INDICATION:


80-year-old male with swollen and tender/erythematous scrotum
 bilaterally.

 COMPARISONS:  None.


FINDINGS:


The testes are normal in echotexture.  The right testis measures
 3.0 x 2.8 x 5.1 cm.  The left testis measures 3.3 x 3.2 x 4.7 cm.  A small
 right hydrocele is noted.  An anechoic rounded focus measuring 9 x 7 x 5 mm
 within the right epididymal head is consistent in appearance with a simple
 epididymal cyst.  The epididymis is otherwise unremarkable.  A small left
 hydrocele is noted.  An anechoic focus measuring approximately 7 mm is noted
 within the left epididymal head consistent in appearance with a cyst.  A small
 shadowing hyperechoic focus measuring approximately 3 mm just adjacent to the
 left epididymal head most likely represents a scrotal pearl.

 Doppler assessment of the testes demonstrates normal arterial and venous
 waveforms.  No increased vascular flow is noted within the testes or
 epididymides.


IMPRESSION:


1.  No evidence of epididymitis/orchitis.
 2.  Bilateral small hydroceles.


Nursing Admission Note
Baby Girl [**Known lastname 3133**] is a term  4.255gm infant delivered by repeat c-section to a 39 yr old A neg. Mom. (see above attending note for maternal history) Infant brought to NICU from reg. nursery with tachypnea. Vital signs on admission Temp 98ax HR 122 RR 64 Sat 99-100 in room air.BP 76/37 M54. Color pink. Lungs clear. Murmur audible. D-sticks followed per LGA protocol and above 50.(see flow sheet) Infant offered bottle feed of E20 x 2 and taking 20cc's. Infant has voided. No meconium passed. Abdomen is soft with good bowel sounds. Dad and grandparents in to visit. Dad updated by [**Known lastname 7**] and RN. A-Resolving tachypnea? retained fetal lung fluid Well appearing newborn (although sibling demise in [**2115**] from alvealor capillary dysplasia)P-Continue to observe in NICU. Transfer to newborn nursery this PM if infant stable.


tsicu npn
o- id- afebrile. levo done. vanco x1 more dose.
neuro/ms- a+o x1, occ. x2-3. pearl. moves toes bilat. moves r arm, lifts and holds, moves l arm on bed. anxious at times. speech difficult to understand at times, ?baseline. mophine iv given 2mg x3 for pain w/repositioning w/effect.
cv- hr 50-70s sr, occ afib 80s-100s, rare pvc. bp 120-160s/. cks total up, mb/treponin neg. cont. on same amiodarone iv. started lopressor po (peditube).
resp- on 2l n/c sats mid to high 90s, no sob. l/s coarse thruout. poor cough effort. sx'd orally for small white.
gu- u/o 20-40cc/hr, lasix 20mg iv x1 at 1615 with 500cc out so far.
gi- abd soft w/bowel sounds. pedi tube in by resident, in good position per xray. started on t/f promote w/fiber at 20cc/hr. no bm.
skin- per flowsheet and has small skin tear r hand, telfa dsg on. repos side to side to back in bed. oob to chair w/[**Doctor Last Name **] lift, tol well. [**Location (un) 17**] J collar on and collar care done. l leg w/ bifurcated cast, foot sl. edematous/ecchymotic.
access- ivs leaking and r reddened. 2 ivs replaced by resident after several attempts by nsg/iv team.
social- fx in off/on this pm. fx updated on pt's condition and plan. son, [**Name (NI) **] is HCP and pt stated today that he still wants [**Doctor Last Name **] to be his HCP.
a-cont. episodes af, although rate controlled. cont. aspiration risk.
p- monitor hr/bp, ?change to diltiazem if still w/afib. ?po amiodarone or d/c. monitor resp. status. will need swallow study. increase t/f as tolerated, goal 60cc/hr. nutrition consult in am.


[** 41**] PHysical  Exam
PE: pale pink, AFOF, breath sounds clear/equal with easy WOb, no murmur, abd soft, non ddsitended, + bowel sounds, active with good tone.

PICC line dressing loose, dressing changed using sterile technique.


MICU Nursing Progress NOte 7a-7p
60 y/o male dx w/ small cell lung CA [**10-15**] w/ mets to adrenals and bone.
Now intubated for resp distress and LLL colaplse. LLL now partially re-expanded post pleural tap.
Neuro-
Sedated on propofol 40m/k/m, and MSO4 5mg/hr, pt MAE, PERLA 2mm/bsk bilat, FC inconsistantly depending on sedation.
REsp-
AC/.40/500/14/srr2-3/5. BS clear x LLL>markedly diminished. CT and CXRY indicates L pleural effusion. Tapped by IP under U/S for 900cc, spec sent for various tests. LLL BS improved to insp wheeze to diminished but less. Psot CXRY showed improvement post tap. Bronch post XRAY sig for thich secretions cleared in L lung. No sig wall impingement seen. To repeat Chest CT [**11-19**].
Treatment for ? pnx w/ vanco, flagyl and levofloxacin. Temp 99po, WBC 16k
CV-
BP 134-180/70-90, HR 90-110SR-ST. ^ BP w/ stimulation, resolved w/ ^ sedation prn.
Fluids-
D5.45NS @ 150/hr, pt is +1200 for day. PM lytes done @1800
GI-
Started TF of respolar @10 psot bronchoscopy, then^20cc/hr @ 1800.
[**Name (NI) 4**]
Wife and son visiting briefly this pm. Updated on present status. will inquire as to progress and plan tomorrrow post CT/general pulmonary evaluation.
RADIATION ONCOLOGY MD CONTACT # IN CHART--[**Doctor Last Name **] [**Hospital 8284**] Cancer Center, [**Location (un) **], MA--[**Telephone/Fax (1) 8285**]. MICU MD given # and to call to inform on status.
A/P
RESP status stable on vent w/ sedation. Monitoring status closely post procedure w/  clinical exam, CXRY and CT.
CV-[**Last Name (un) **] on sedation. Probable baseline HTN. Fluids- check 6pm lytes
ID- T 99, cont antibx, monitor.
Endo- RISS per rpotocol.
Social- Support and inform pt and family of status, progress and plan appropriate to dx. Wife wishes pt to be as comfortable as possible while intubated.


TITLE:
   Chief Complaint:  Shortness of breath
   HPI: [**Age over 90 52**]M PMH CHF EF 35-40% with multiple recent admissions for
   exacerbations, CAD, CRF (baseline creatinine 3.8-4), DM2, admitted from
   [**Hospital 12**] Rehab after admission to OSH with GIB, presenting with SOB the
   morning of admission.  The patient's O2 sat was noted to be 92% on 2L
   NC, then dropped to the 80s.
   Of note, the patient was recently admitted to OSH with GI bleed.  ASA
   was discontinued, and his dose of lasix was decreased from 60 mg PO BID
   to 20 mg PO daily.
   In the ED, VS 99.8 91-103 104/55 30 90% NRB->100%BiPAP.  Exam was
   significant for bilateral crackles; stool is guaiac negative and is
   brown.  CXR showing bilateral pulm congestion.  Sign-out was that the
   patient received lasix 60 mg IV x1, however, there is no record of this
   medication being administered.  Urine output 50cc in the ED.  BP


Nursing


#1O:  Received infant on nasal cannula and placed on prong
CPAP 7 after several episodes of desats all with apnea most
requiring bagging to resolve.  Since being placed on CPAP
episodes have become less [** 2399**]. and most don't require
bagging.  br. sounds clear with mild SC retractions.  O2
req. 23 - 30%, increased when having desats.  Did have 1
dose of Combivent after being placed on CPAP.
#2O:  Wt. up 45g on 120cc/kg, PN D10.  Remains NPO d/t resp.
status.  Belly soft, full, slightly firm (probably d/t
bagging, stomach has been decompressed several x's).  Urine
out 3.9cc/kg, no stool.
#3O:  [** 2**] into visit at time that daughter was being
placed back on CPAP and were updated at the bedside by NNP,
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 81**], resp. therapist, and this RN.  [**Last Name (NamePattern4) 2**]
understandably upset that daughter has had this set back.
#5O:  Remains on warmer for easy access.  Swaddled and
sucrose pacifier given  @ x's.  Tylenol given x 1.  Eye meds
given as ordered.


ROS:

Neuro: Pt slept well, A/O X 3, denies numbness or tingling. PRN MSo4 with good pain control. Continues to have neck flexed, no extension, sigh placed above bed.

CV: SB-SR 50s-60s, no ectopy noted. Art line with good wave form shows Bp consistently in 130s-140s/ 50s. DP/PT pulses present and easily palpable.

Pulm: Had been on 3 liters per nasal cannula most of shift, switched over to humidified face tent ~0600 due to nose bleed-pt reported her nose was irritated from O2 and she felt dried out. Face tent at 40% O2. RR 10-20, O2 sats consistently 98-100%. Good productive cough. PT denies SOB.

GI: Took PO well, to have reg diet today. +BS, -stool, episode X 1 of nausea and emisis ~50cc at 0600, received 4 mg zofran with good effect.

GU: Adequate UOP, clear/yellow. K needs replacement- to give with food soas to not irritate stomach. Foley patent to gravity.

ID: Afebrile, receiving flagyl and cefazolin.

Skin: DSD on inferior portion of neck with 1 JP, output ~29cc ss drainage. Skin otherwise intact, pink/warm/dry.

Social: No contact this shift.

A: Pt henodynamically stable, O2 sats good, no SOB or desaturation.

plan: Progress diet, Give KCL, Monitor Nausea/vomiting-protect airway. ENsure adequate oxygenation, update family and provide support.


[**2197-6-16**] 4:34 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 5**] # [**Clip Number (Radiology) 81624**]
 Reason: PICC REPOSITIONING
 Admitting Diagnosis: ACUTE RENAL FAILURE/ANEMIA
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


PICC position.

 Single supine frontal radiograph compared to study done 10 minutes earlier
 demonstrates the left-sided PICC to still be malpositioned within the right
 subclavian vein.  There have been no other changes.


Sinus rhythm. Prior anteroseptal myocardial infarction. Compared to the
previous tracing of [**2166-4-9**] there are continued ST segment abnormalities,
somewhat more prominent, reflected in the ST segment depression in
leads I, aVL, II, aVF and V3-V6. Rule outy infarction. Followup and clinical
correlation are suggested.
TRACING #2


[** 18**] Physical Exam

PE: pink, well perfused, AFOF, suture approximated, breath sounds clear/equal with fair to good air entry, some shallow respirations, minimal retracting, no murmur, +2 pulses upper and lower extrem, abd soft, full, active bowel sounds, active with good tone.


altered cardiac status
s: mouthed "I'm nauseaous" "headache"
o: cardiac: sr 80's-90's without vea, no af, amiodarone continues @.5mg,iv ntg presently @ 1.5 mcq, lopressor,k,hydralazine given via ngt. captopril 1st dose @ 1400. extremities warm to touch. +PP.cvp14-18.
   resp: tolerating cpap 5/5 not extubated due to awaiting further diuresis. tv 400's,rr teens, bs course clears with sx however small amount of white thin sputum sx only. bs diminished basilar. o2 sats>87%.
   neuro: calm, perl, mae,following commands.
   gi: tolerating tf max @ 60, 12 noon residual 60 ml, 1400 residual 20 ml. c/o nausea recieved 10 mg reglan with good effect. + bowel sounds, incontinent of stool, fib applied and intact.
   gu: recieving 80 mg ivp lasix q 6 hr today, with good diuresis.k 3.4 recieved 80 meq kcl x1. k to be drawn @ 1600.
   skin: intact, heels reddened positioned on pillow.
   endo: insulin gtt of due to glucose 68 presently @ 4 units. hourly glucoses being checked.
   pain: recieved 5ml percocet for c/o ha x2 with good effect.
a: tolerating cpap5/5, continues to diureses with laix 80 mg atc,labile blood sugars
p: monitor comfort, hr and rythym, sbp- wean ntg if tolerated(pt c/ontg giving her a ha),captopril increased to 25 mg @ 1600, resp status, neuro status, i+o, labs, as per orders.


Admission Note
[**Known lastname 68**] is being readmitted from [**Hospital3 200**] s/p ventriculoperitoneal shunt placement by Dr [**Last Name (STitle) 229**] [**10-14**].

Well known to us; 28 wker now 36+ wks corrected s/p initial delivery at [**Hospital1 232**] transfer to CH due to limited NICU bed availability.  Difficult early course including severe RDS/pulmonary hemorrhage; hypotension req dopamine, presumed PDA with 1 course Indocin; hypertension/tachycardia; multiple PRBC transfusions & FFP r/t pulm hemorrhage; bilateral IVH with dilation noted DOL3, progressed to intraparenchymal bleed on R by DOL5.

IVH progressed to PHH while at CH; unresponsive to serial LPs; subgaleal shunt placed by Dr [**Last Name (STitle) 229**] [**9-9**].  Readmitted to [**Hospital1 177**] [**9-11**]; subgaleal shunt malfunction noted due to increasing HC (with head u/s confirmation of ventriculomegaly) early [**Month (only) 50**].  Subgaleal shunt reservoir tapped with adequate CSF removal, but head u/s unchanged; to CH for VP shunt placement [**10-14**].

Intraoperatively received 10cc/kg PRBCs; minimal EBL.  Also got Ancef x3 periop.  Getting Tylenol q8 for pain control (had a/b postop s/p morphine - got Narcan).
HC postop 32cm.  Sutures are absorbable; dressing can come off in 1wk; f/u with Dr [**Last Name (STitle) 229**] 2-4wks.
Weaned to RA yesterday.
Advanced to full enteral feeds 120cc/kg/24hrs 20cal human milk pg.
Still on contact precautions due to h/o colonization with Pseudomonas.

BP on adm 78/44 mean 56
PE  active, [**Last Name (STitle) **], appropriate (fussy - due for feed).  [**Last Name (STitle) **] [**Last Name (STitle) 22**] in RA.  NGT in place.  AF now flatter than prior to transfer.  Dressings in place at vertex, occiput - dry & intact.  Lungs CTA, mild rtx; heart RRR s murmur; abd with dressing dry & intact, +BS, soft, no masses.  Extr well perfused.  Appropriate/symmetric [**Last Name (STitle) 225**], movt; inconsistent but at times well-coordinated, strong suck.

Imp/ 36+wk former 28wk triplet doing well post VPS placement for PHH.  Age-appropriate feeding immaturity.  Anemia of prematurity - now s/p transfusion.

Plan/ continue to monitor HC; consider check head u/s Monday.  Continue to monitor cvr status, feeding tolerance - will increase back to baseline feeds of TF150 Mm30 with promod.  d/c planning in progress contingent on further evidence of maturity.


#2Resp
Lungs clear with mild sc retractions. RR 30-60. Sat in high
90's. No spells so far tonight.
A. [** **] RA
P. Cont to monitor.
#3FEN
Wt 1.91 up 25g. Baby cont to receive SC26 48cc on pump over
70 min. No spits so far tonight. Abd round but soft. AG 23
cm. Void and stooling heme neg. Min asp.
A. [** **] feed
p. Cont to monitor [** 53**] to feed as well as weight gain
#4Parent
no contact tonight
#5Dev
[**Name2 (NI) 54**] stable in an open crib. Slept well between cares. Awake
and alert with cares. Swaddled on sheepskin with boundaries.


(Continued)
SPEAK WITH HIM VIA PHONE WHEN HE IS ABLE. ? IF SHE WILL BE VISITING IN NEXT FEW DAYS. EXPRESSED FRUSTRATION WITH "I KNEW THIS WAS BOUND TO HAPPEN ONE DAY. I JUST HOPE THAT THIS IS WHAT GETS HIM TO CHANGE." CONTINUE TO PROVIDE SUPPORT AS NEEDED.

PLAN: CONTINUE WITH HEMO, NEURO, AND PULMONARY MONITORING. TURN AND REPOSITION FREQUENTLY. MEDICATE WITH ATIVAN, HALDOL AND MORPHINE AS NEEDED FOR SEDATION/PAIN CONTROL. WEAN PROPOFOL DOWN AS TOLERATED. MAINTAIN KNEE IMMOBILIZER AND LEFT ARM SPLINT. MAINTAIN C-COLLAR. CONTINUE CPAP/PSV AS TOLERATED. PROVIDE ONGOING FAMILY AND PT SUPPORT.


Resp Care Note, Pt remains on current vent setting. See vent flow sheet for details . Suctioned for sml amts thick tan secretions.Sedated with propofol.Will cont to monitor resp status.


Chief Complaint:
   24 Hour Events:
   - C/o abdominal and leg pain; could not elaborate. Gave ultram x 1 and
   simethicone for bloating
   - Was more alert and verbal
   - Sodium in the evening was 150, thus D5W at 175cc/hr to correct
   hypernatremia
   - O2 sats in mid-90s with 4-5L O2 NC
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Piperacillin/Tazobactam (Zosyn) - [**2174-3-27**] 04:08 AM
   Vancomycin - [**2174-3-27**] 08:00 PM
   Piperacillin - [**2174-3-28**] 04:14 AM
   Infusions:
   Other ICU medications:
   Lansoprazole (Prevacid) - [**2174-3-27**] 08:00 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  [**2174-3-28**] 07:09 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.4
C (99.3
   Tcurrent: 37.2
C (99
   HR: 89 (87 - 101) bpm
   BP: 113/57(70) {96/49(61) - 131/67(79)} mmHg
   RR: 10 (7 - 22) insp/min
   SpO2: 98%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 65 Inch
    Bladder pressure: 16 (16 - 16) mmHg
   Total In:
                                                                  5,424 mL
                                                                  1,940 mL
   PO:
   TF:
                                                                    550 mL
                                                                    358 mL
   IVF:
                                                                  3,284 mL
                                                                  1,402 mL
   Blood products:
   Total out:
                                                                  5,050 mL
                                                                  1,430 mL
   Urine:
                                                                  1,700 mL
                                                                    430 mL
   NG:
   Stool:


Abdominal compartment syndrome / Intraabdominal Hypertension (IAH, ACS)
   Assessment:
   abdomen open and distended.
   Action:
   NEO titrated to off
   gtube to gravity-jtube clamped for meds
   jp drains to wall suction
   flexiseal patent
   Response:
   MAP> 60 off NEO
   bladder pressures 18-20
   tolerated clamped jtube
   jp drainage light sero/sang
   Plan:
   OR on monday
   Pain control (acute pain, chronic pain)
   Assessment:
   fentanyl gtt @250mcg. Ketamine 10mg. grimace scale
   Action:
   no increase or bolus needed
   Response:
   grimaces when moved but falls back to sleep quickly
   Plan:
   continue @current rate
   Renal failure, acute (Acute renal failure, ARF)
   Assessment:
   CRRT continuous, general edema, oliguria
   Action:
   PFR increase as tolerated by BP
   calcium and potassium infusions
   citrate @260 ml/hr
   lyte repletions
   Response:
   stable; weight down 5.5kg this am
   Plan:
   continue to pull off fluid as tolerated


SICU
   HPI:
   52M w/ esophageal ca s/p esophagectomy w/ colonic interposition [**4-22**],
   s/p takeback for ileocolonic reanastamosis [**4-23**], s/p resection of failed
   interposition graft [**4-25**], s/p abd closure [**4-28**], now w/ EC fistula.
   Chief complaint:
   esophageal ca
   PMHx:
   PMH: MI, HTN, PVD, benign pancreatic mass
   PSH: Whipple, aorto-bifemoral bypass, R CEA '[**91**], SFA angioplasty, knee
   arthroscopy
   [**Last Name (un) 574**]: Diovan 160', atenolol 50', simvastatin 40', MVI'
   Current medications:
   1. Magnesium Sulfate  IV Sliding Scale maintain Mg>2.0  Order date:
   [**4-28**] @ 1104
   2. Meropenem 500 mg IV Q6H  Order date: [**5-19**] @ 0933
   3. Metoprolol Tartrate 5 mg IV Q6H hold for SBP < 100, HR < 60  Order
   date: [**5-20**] @ 1323
   4. Acetaminophen 650 mg PO Q6H:PRN fever; temp> 101.4 or per rectum
   prn.  Order date: [**4-30**] @ 2200
   5. Nystatin Oral Suspension 5 mL PO QID:PRN  Order date: [**4-29**] @ 2035
   6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN  Order date: [**5-8**] @ 1610
   7. Octreotide Acetate 100 mcg SC Q8H  Order date: [**5-18**] @ 1701
   8. Artificial Tear Ointment 1 Appl BOTH EYES PRN  Order date: [**4-28**] @
   1104
   9. Ondansetron 4 mg IV Q8H:PRN  Order date: [**4-28**] @ 1104
   10. Calcium Gluconate  IV Sliding Scale Order date: [**4-28**] @ 1104
   11. Piperacillin-Tazobactam Na 4.5 g IV Q8H fistula  Order date: [**5-10**]
   @ 0130
   12. Famotidine 20 mg IV Q12H  Order date: [**5-10**] @ 0857
   13. Potassium Chloride  IV Sliding Scale maintain K>4.0  Order date:
   [**4-28**] @ 1104
   14. Fluconazole 400 mg IV Q24H  Order date: [**5-16**] @ 1039
   15. Potassium Phosphate  IV Sliding Scale Infuse over 6 hours  Order
   date: [**4-28**] @ 1104
   16. Fondaparinux Sodium 2.5 mg SC DAILY  Order date: [**4-30**] @ 0832
   17. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain  Order date: [**5-19**]
   @ 0933
   18. Insulin SC  (per Insulin Flowsheet) Sliding Scale Order date: [**5-15**]
   @ 0906
   24 Hour Events:
   [**Month (only) 38**]'d Lopressor to 5q6, JP output sent for amylase and t.bili
   Post operative day:
   POD#29 - s/p gastrrectomy, transhiatal esophagectomy r colon pullup
   POD#23 - Abdominal closure.
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Fluconazole - [**2195-5-20**] 02:15 PM
   Piperacillin/Tazobactam (Zosyn) - [**2195-5-21**] 04:17 AM
   Meropenem - [**2195-5-21**] 06:14 AM
   Infusions:
   Other ICU medications:
   Fondaparinux - [**2195-5-20**] 10:30 AM
   Metoprolol - [**2195-5-20**] 04:15 PM
   Famotidine (Pepcid) - [**2195-5-21**] 12:19 AM
   Other medications:
   Flowsheet Data as of  [**2195-5-21**] 06:35 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**98**] a.m.
   Tmax: 37.8
C (100.1
   T current: 37.7
C (99.8
   HR: 98 (87 - 105) bpm
   BP: 100/56(66) {93/51(61) - 125/73(89)} mmHg
   RR: 26 (22 - 39) insp/min
   SPO2: 95%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 54.7 kg (admission): 59.1 kg
   Height: 66 Inch
   CVP: 1 (1 - 1) mmHg
   Total In:
                                                                  2,526 mL
                                                                    382 mL
   PO:
   Tube feeding:
   IV Fluid:
                                                                    920 mL
                                                                    382 mL
   Blood products:
   Total out:
                                                                  2,855 mL
                                                                    760 mL
   Urine:
                                                                  2,725 mL
                                                                    690 mL
   NG:
                                                                     80 mL
   Stool:


Subjective
   patient sleeping
   Objective
   Height
   Admit weight
   Daily weight
   Weight change
   BMI
   178 cm
   63 kg
   74.9 kg ([**2113-2-3**] 04:00 AM)
   19.9
   Pertinent medications: D5 @10 ml/hr, KCl (40 mEq repletion), RISS, IV
   abx, lansoprazole, famotidine, others noted
   Labs:
   Value
   Date
   Glucose
   73
   [**2113-2-4**] 12:00 PM
   Glucose Finger Stick
   135
   [**2113-2-4**] 12:00 AM
   BUN
   25 mg/dL
   [**2113-2-4**] 03:42 AM
   Creatinine
   1.6 mg/dL
   [**2113-2-4**] 03:42 AM
   Sodium
   140 mEq/L
   [**2113-2-4**] 03:42 AM
   Potassium
   3.5 mEq/L
   [**2113-2-4**] 03:42 AM
   Chloride
   108 mEq/L
   [**2113-2-4**] 03:42 AM
   TCO2
   22 mEq/L
   [**2113-2-4**] 03:42 AM
   PO2 (arterial)
   65 mm Hg
   [**2113-1-31**] 04:47 AM
   PO2 (venous)
   48 mm Hg
   [**2113-1-21**] 05:21 PM
   PCO2 (arterial)
   30 mm Hg
   [**2113-1-31**] 04:47 AM
   PCO2 (venous)
   33 mm Hg
   [**2113-1-21**] 05:21 PM
   pH (arterial)
   7.46 units
   [**2113-1-31**] 04:47 AM
   pH (venous)
   7.43 units
   [**2113-1-21**] 05:21 PM
   pH (urine)
   5.5 units
   [**2113-2-1**] 07:16 AM
   CO2 (Calc) arterial
   22 mEq/L
   [**2113-1-31**] 04:47 AM
   CO2 (Calc) venous
   23 mEq/L
   [**2113-1-21**] 05:21 PM
   Albumin
   2.1 g/dL
   [**2113-2-1**] 02:44 PM
   Calcium non-ionized
   7.3 mg/dL
   [**2113-2-4**] 03:42 AM
   Phosphorus
   3.1 mg/dL
   [**2113-2-4**] 03:42 AM
   Ionized Calcium
   1.08 mmol/L
   [**2113-1-30**] 11:46 AM
   Magnesium
   2.0 mg/dL
   [**2113-2-4**] 03:42 AM
   ALT
   23 IU/L
   [**2113-2-3**] 05:24 AM
   Alkaline Phosphate
   51 IU/L
   [**2113-2-3**] 05:24 AM
   AST
   24 IU/L
   [**2113-2-3**] 05:24 AM
   Amylase
   40 IU/L
   [**2113-2-3**] 05:24 AM
   Total Bilirubin
   0.3 mg/dL
   [**2113-2-3**] 05:24 AM
   Triglyceride
   120 mg/dL
   [**2113-1-25**] 03:36 AM
   WBC
   13.4 K/uL
   [**2113-2-4**] 03:42 AM
   Hgb
   9.8 g/dL
   [**2113-2-4**] 03:42 AM
   Hematocrit
   29.7 %
   [**2113-2-4**] 03:42 AM
   Current diet order / nutrition support: NPO
   GI: soft, hypoactive bowel sounds
   Assessment of Nutritional Status
   Specifics: Patient s/p video swallow [**2-3**] which recommended patient be
   NPO. Received consult for PPN recommendations. Per discussion with PA,
   plan is for PEG placement on Monday and to supplement nutrition with
   parenteral nutrition until PEG is able to be used. Patient with PICC,
   Day 1 TPN ordered to start tonight. NGT was attempted earlier in week
   and was unable to placed and team thinks patient would pull it out.
   Medical Nutrition Therapy Plan - Recommend the Following
   1.       Day 1 TPN tonight
   2.       Pending glycemic control advance to goal TPN 1.6L (270 g
   dextrose/80 g amino acids/35 g lipids)= 1588 kcals
   3.       Check TG hold lipids if greater than 400
   4.       Once PEG placed start with Isosource HN @ 15 ml/hr advance to
   goal of 45 ml/hr = 1620 kcals/ 73 g protein
   5.       Will follow page [**Numeric Identifier 1372**] with questions


Neonatology Attending Note
DOL#6, CGA 28 wks

Last night switched from HFOV to IMV.
On 20/6 x 22, RA
Clear BS, RR 30-60s
7.26/44
Cloudy secretions, no further blood
On caffeine

No murmur
P 130-160s
MBP 55
Small PDA by ECHO Friday

Wt 936 (up 22 gm)
NPO, on TF 130 cc/kg
Central PICC in place
D-stick stable
UO 3.1 cc/kg/hr.
Trace stool

On single phototherapy
Temps stable in open warmer

A/P:
Premature infant s/p pulmonary hemhorrhage, RDS, hyperbilirubinemia
RESP:  Continue to wean vent as tolerated.
CV:  PDA likely gone.  Will defer ECHO given lack of any signs of clinically significant duct.
FEN:  Start trophic feeds, and continue PN and follow lytes.
GI:  Continue phototherapy and monitor bili.
NEURO:  Plan for f/u HUS this week.
SOC:  Keep family updated.


.H/O abdominal pain (including abdominal tenderness)
   Assessment:
   Pt with abdominal pain [**2125-6-19**].
   Action:
   Medicated with dilaudid 0.5mg Q3hrs.
   Billiary drain placed in US.
   Response:
   150cc dark brown bile drained.
   Pt now comfortable.
   Plan:
   Monitor pt overnight for signs of infection.
   Transfer to floor in am.
   Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)
   Assessment:
   Pt febrile overnight to 101.5F.
   Action:
   Started on Unasyn overnight.
   Response:
   A-febrile.
   Plan:
   Monitor overnight.


Sinus rhythm.  Left axis deviation.  Prior inferior myocardial infarction.
No previous tracing available for comparison.


[**2170-2-20**] 1:55 AM
 BABYGRAM (ABD ANY SGL VIEW) ([**Numeric Identifier 132**]) PORT                        Clip # [**Clip Number (Radiology) 85916**]
 Reason: r/o nec
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


Infant with aspirate with blood flecks in it, normal abdominal exam


REASON FOR THIS EXAMINATION:


r/o nec
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Bloody aspirate from NG tube.

 SUPINE VIEW OF THE ABDOMEN obtained portably compared with [**2170-1-19**]
 demonstrates mild gasseous distention of multiple loops throughout the abdomen
 to the level of the rectum with a paucity of gas in the pelvis likely due to a
 distended urinary bladder. No evidence of obstruction or pneumatosis or portal
 venous gas. No organomegaly. NGT terminates in the left upper quadrant. Some
 mild interstitial prominence is present in the lung bases in keeping with
 chronic lung disease.


ccu nsg progress note.
o:neuro=lightly sedated w propofol gtt. responsive @ x's-nodding head to questions-not consistant. easily agitated w decrease in gtt.
  pulm=intubated & sedated-only vent chg--decreased peep from 8 to 5. gd abg/sats. breath sounds=deminished/course throughout. sx-@x's copious amts watery white secretions. abundant oral secretions.
  cv=very labile bp-requiring freq adjustment of dopa gtt to maint adeq maps. dopa gtt presently @ 8mcg/kg/min. iabp 1:1 chged to 1:2 x4hrs w stable maps/pad/co-ci/svr--placed back on 1:1 to rest. heparin gtt restarted-follow up ptt-130. heparing gtt stopped @ 0545. r fem site w ooze-pressure dsg applied. vasc [**Doctor First Name **] aware/seen.
  gi=tpn as ordered. tf held due to significant amt ogt drainage. hypoactive bowel sounds. wo stool.
  endo=insulin gtt titrate to maint adeq bs.
  renal=cvvhdf-filter cloted 0100-resumed 0300. presently pfr set to keep i&o essentially equal due to increased requirement of dopa (decreased maps). gtts-cal gluc & k-adjusted to am labs.
  id=afebrile.
  skin=coccyx w duoderm.

a:requiring increased dose dopa to maint adeq maps. contin ooze from r fem site. unable to start tf due to signif drainage from ogt. present keeping i&o equal due to decreased maps.

p:contin present managment. ?attempt wean/dc iabp. increase pfr as tolerated. contin freq (q1hr) bs. support pt/family as indicated.


NPN

#1 S. O.  Infant remains on a nasal cannula with fio2 at
100%.  Flow weaned from 25cc to 13cc.  Color pale pink.
Breath sounds clear and equal.  A.  Infant requiring some
respiratory support.  P.  Assess for weaning.

#2 S. O.  Weight down 15 grams.  Voiding.  Infant passed one
small stool.  Infant offered a po feed at the 2400 care with
infant only taking 6cc po. The remainder of feeds of breast
milk 28 calorie with promd were given ng.  total volume at
120cc/kgd/ay.  Piv heplocked and later d/c'd.  D stick 81.
A.  Infant to all po feeds.  P.  Monitor for intolerances.

#5 S. O.  Mom called x 1 for an update.  A.  [** **] parent.
P.  Support and keep updated.

#10 S. O.  Dressing D& I.  No drainge from circ site.
Bacitracin applied to area.  Infant given Tylenol x 2 and
oral sucrose with good effect.  A.  S/P hernia repair and
circ.  P.  Continue to monitor .


[**2118-2-23**] 8:35 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 66139**]
 Reason: Evaluate for postoperative changes.
 ______________________________________________________________________________
                                 FINAL ADDENDUM
 There is no significant change in the slightly dense left sided subdural
 collection at the surgical site with mild displacement of the left cerebral
 hemisphere. ( se 2, im 20)



 [**2118-2-23**] 8:35 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 66139**]
 Reason: Evaluate for postoperative changes.
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


50 year old woman post cranioplasty.


REASON FOR THIS EXAMINATION:


Evaluate for postoperative changes.
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Status post cranioplasty, followup evaluation.


COMPARISON:


Most recent CT head done on [**2117-1-24**].


TECHNIQUE:


Non-contrast CT head.


FINDINGS:


The patient is status post cranioplasty on both sides in the frontal and the
 parietal regions.
 Post-surgical changes are noted.  There is no new acute intracranial
 hemorrhage, mass effect, shift of normally midline structures or
 hydrocephalus.  Lobulated slightly hyperdense areas noted at the vertex, in
 the left parasagittal location and along the right convexity, related to the
 previously noted extra-axial masses felt to represent meningiomas.  These are
 inadequately assessed on the present study as well as the patency of the
 adjacent venous sinuses.Hypodense area noted at the right vertex, in the
 frontal lobe, in a vasogenic edema pattern around the extra-axial masses, is
 not significantly changed from the prior study.


IMPRESSION:


1.  No acute intracranial hemorrhage.  The known extra-axial dural-based
 lesions at the vertex are again visualized, however, inadequately assessed on
 the present study.  Hypodense area in the right frontal lobe at the vertex
 relates to vasogenic edema around the dural-based lesions rather than
 encephalomalacic changes.  Attention on followup as clinically indicated.  If
 there is concern for detailed assessment of the meningiomas, including patency
 of the venous sinuses, MR can be considered if not contraindicated.

 Other details as above.


[**Doctor Last Name 470**],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 471**]                   MED MICU                   [**2155-2-13**]  2:50 PM
 IVC GRAM/FILTER                                                 Clip # [**Clip Number (Radiology) 84863**]
 Reason: Please place removable IVC filter.
 Admitting Diagnosis: PULMONARY EMBOLI
  Contrast: OPTIRAY Amt: 85
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


64 year old man with b/l central PE with extensive RLE clot burden.


REASON FOR THIS EXAMINATION:


Please place removable IVC filter.
 ______________________________________________________________________________
                                  PFI REPORT
 Successful deployment of IVC filter in infrarenal position.


neonatology
Doing well. Remains in NCO2. Low flow. Incresaed flow with feeds.
Intermittent murmur. Comfortable appearing. Spells not a problem on spells.

Wt [**2101**] up 70. TF 140 cc/k/d. On 32 cal and tolerating well. Took full bottle this am. Abdomen benign.

Eyes immature.

PMD will be Dr [**Last Name (STitle) 3896**] in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 718**].

Continue as at present.


[**2159-5-13**] 4:37 PM
 MR CERVICAL SPINE                                               Clip # [**Clip Number (Radiology) 77664**]
 Reason: eval for cord compression
 Admitting Diagnosis: ALTERED MENTAL STATUS;TELEMETRY
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


56 year old man with end-stage liver disease, chronic kidney disease, ? cord
  compression on CT in neck collar


REASON FOR THIS EXAMINATION:


eval for cord compression
 ______________________________________________________________________________


FINAL REPORT


CERVICAL SPINE MRI SCAN:


HISTORY:


End-stage liver disease and chronic kidney disease.  Question of
 cord compression on CT of the neck.  Evaluate for cord compression.


TECHNIQUE:


Multiplanar T1 and T2-weighted as well as axial gradient echo
 scans of the cervical spine.

 COMPARISON STUDY: CT of the cervical spine dated [**2159-5-2**] interpreted by
 doctors [**Name5 (PTitle) 1810**] and [**Name5 (PTitle) 14154**] as revealing "osteophytes at C5-6 cause moderate to
 severe narrowing of the spinal canal on the right and likely compress the
 spinal cord."


FINDINGS:


Unfortunately, a number of the imaging sequences are of limited
 resolution due to patient motion.  In that regard, the sagittal T1-weighted
 scans are nearly uninterpretable, despite repeat scanning attempts.


FINDINGS:


At C4/5, uncovertebral spurring produces prominent left and
 moderate right-sided neural foraminal stenosis, in [**Location (un) 11438**] with the recent CT
 scan.

 At C5/6, a moderate posterior spondylytic ridge causes moderate deformity of
 the spinal cord along its ventral margin with a slight caudal extension of the
 ridge to the right of midline, again mildly deforming the right ventrolateral
 cord margin.  Motion artifacts render foraminal dimension assessment
 difficult, but I believe uncovertebral spurring at this locale again causes
 prominent foraminal stenosis, in [**Location (un) 11438**] with the recent CT scan.  This disc is
 moderately narrowed.  No other overt spinal or paraspinal pathology is seen.

 CONCLUSION:  Poor quality imaging secondary to patient motion but with
 reasonable correspondence of the MR [**First Name (Titles) **] [**Last Name (Titles) **] findings as noted above.

 COMMENT:  There are probable secretions layering within the oro- and
 nasopharynx regions.  Apparently, the patient is intubated.


[**Last Name (LF) 14061**],[**First Name3 (LF) **] P.                   MED FA10                   [**2111-8-7**]  1:36 PM
 PICC LINE PLACMENT SCH                                          Clip # [**Clip Number (Radiology) 30913**]
 Reason: Please place PICC line.
 Admitting Diagnosis: ACUTE RENAL FAILURE;TELEMETRY
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


56 year old woman with ESLD, hepatic sarcoidosis, multiple recurrent SBOs with
  previous PICC line sepsis.


REASON FOR THIS EXAMINATION:


Please place PICC line.
 ______________________________________________________________________________
                                  PFI REPORT
 PFI:  Placement of PICC line via the left brachial vein access with the tip of
 the catheter in SVC, and the catheter is ready to use.


TITLE:
   Chief Complaint:
   24 Hour Events:
   - HD yesterday
   - Heme/Onc will consult today
   - More PVCs on tele
   Speech and Swallow RECOMMENDATIONS:
   1. Video swallow to further assess swallowing function and
   determine safest and least restrictive PO diet.
   2. Initiate PO intake of nectar thick liquids and soft solids
   with PMV in place for ALL POs.
   3. Pills crushed with puree.
   4. 1:1 supervision for all POs.
   5. Q6 oral care.
   Allergies:
   Vancomycin
   Rash;
   Last dose of Antibiotics:
   Piperacillin/Tazobactam (Zosyn) - [**2107-12-18**] 06:00 AM
   Infusions:
   Other ICU medications:
   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  [**2107-12-20**] 07:25 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.2
C (100.8
   Tcurrent: 37.4
C (99.3
   HR: 85 (80 - 110) bpm
   BP: 120/49(65) {95/49(63) - 152/80(91)} mmHg
   RR: 31 (12 - 31) insp/min
   SpO2: 100%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 87 kg (admission): 110 kg
   Height: 70 Inch
             Total In:
                                                                    900 mL
                                                                    414 mL
   PO:
                                                                    300 mL
                                                                    240 mL
   TF:
   IVF:
                                                                    540 mL
                                                                    174 mL
   Blood products:
   Total out:
                                                                  4,780 mL
                                                                      0 mL
   Urine:
                                                                    180 mL
   NG:
   Stool:


Respiration / Gas Exchange, Impaired
   Assessment:
   Pt A/O times 2 .   Nods head to yes/no .Lethargic and sleepy during
   morning hours, more awake   since midday.  Remains on 50%  12L trach
   mask. 02 sats 94-98%  LS  with rhonchi  in upper lobes, diminished  at
   bases. Pt has strong cough, coughing thick tan to blood tinged
   secretions.   Slightly tachypneic this shift with RR between 32-38.
   Denies any discomfort. Team aware. Afebrile , Tmax  98.6 oral
   Action:
   Frequently suctioning out thick  scant to moderate amounts of thick
   tan/blood tinged  secretions .  Continues on IV Vanc and Zosyn.  Pt
   followed up by PT today, made to sit  at side of the bed, tolerated it
   for only approx 10 mins. Pt then started to desat to 88%, was
   transferred to bed.
   Response:
   Spo2 stable on above O2 settings. Continues to be slightly tachypneic.
   Remains afebrile .
   .
   Plan:
   Cont to closely monitor resp status/oxygenation. Frequent pulmonary
   toileting, oral care. Follow temp curve,  pan culture if needed.  OOB
   to stretcher as per pt
s tolerance.
   f/u with sputum culture from [**3-7**].
   Alteration in Nutrition
   Assessment:
   Receiving TPN as ordered.
   Hypo BS, abd soft non-tender.
   Brown liquid stool via flexi-seal cath.
   PEG tube to gravity, draining bilious.
   Action:
   Started TF
s (Vivonex Full) at 10ml/hr via post-pyloric tube at 0100.
   Response:
   Cont TPN, PEG remains to gravity.
   Flexi-seal in place.
   Plan:
   Monitor tolerance of TF
   Increase rate by 10ml/hr q6hours (goal 85ml/hr)
   Cont TPN until TF
s at goal rate.
   Impaired Skin Integrity
   Assessment:
   Mepilex dressing on coccyx remains D/I.


Respiratory Care Note:
Pt remains intubated and on the ventilator. Pt remains on PSV, tolerating well. Suctioned for small amounts of thick white sputum. Pt traveled to CT, uneventful. Plan: wean down support as tolerated. See careview for additional vent settings and info.


[**2174-6-29**] 1:19 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 68355**]
 Reason: stroke?
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


49 year old man with new R sided paralysis, normal about 2hrs ago


REASON FOR THIS EXAMINATION:


stroke?
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: AGLc WED [**2174-6-29**] 2:27 AM
  Large left frontoparietal intraparenchymal hemorrhage 8.1 x 4.8 cm, causing 8
  mm rightward shift of normally midline structures.  Intraparenchymal
  hemorrhage also inferior right frontal and left temporal.  Extra-axial
  hemorrhage along left occipitoparietal region, measuring up to 13 mm
  posteriorly, and along falx.  likely impending left uncal herniation.  fluid
  nasal cavity.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


49-year-old male with new right-sided paralysis who was normal two
 hours prior.  Concern for stroke.


COMPARISON:


CT head most recently of [**2174-4-2**].


TECHNIQUE:


MDCT axial imaging was performed through the brain without
 administration of IV contrast.

 NON-CONTRAST HEAD CT:  The patient is intubated with OG tube in place.  There
 is new large intraparenchymal hemorrhage centered in the left frontoparietal
 region measuring up to 8.1 x 4.8 cm on axial imaging (2:18).  This causes 8 mm
 rightward shift of normally midline structures.  Additional foci of
 intraparenchymal hemorrhage is seen in the inferior right frontal lobe as well
 as in the left temporal lobe.  Right temporal sulcal high density may
 represent acute subarachnoid hemorrhage.  There is diffuse sulcal effacement
 in the left cerebral hemisphere as well as mass effect on the left lateral
 ventricle.  No intraventricular extension of hemorrhage is seen. There is
 extra- axial hemorrhage along the left occipitoparietal region, measuring up
 to 13 mm thick posteriorly.  High- density blood is also seen layering along
 the falx.  In addition to rightward subfalcine herniation, asymmetric widening
 of the left aspect of the perimesencephalic cistern may represent early left
 uncal herniation.  There is effacement of the left suprasellar cistern.

 The soft tissues, orbits, and skull appear intact.  There is fluid within the
 nasal cavity and mild mucosal thickening in the maxillary sinuses, with mucous
 retention cyst in the left maxillary sinus.  The mastoid air cells and
 external auditory canals are normally aerated.


IMPRESSION:


Large left frontoparietal intraparenchymal hemorrhage causes
 rightward subfalcine herniation and likely impending left uncal herniation.
 Right inferior frontal and left temporal intraparenchymal hemorrhage and right
 temporal subarachnoid hemorrhage.  Left extra-axial likely subdural
 hemorrhage.

                                                             (Over)

 [**2174-6-29**] 1:19 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 68355**]
 Reason: stroke?
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 Findings were initially posted on the ED dashboard upon completion of the
 study and neurosurgical consultation has been obtained for the patient.
 Close follow up as indicated and work  up for the cause.


Vent change made to peep 7, ps 6 per Dr. [**Last Name (STitle) 3485**] team.


[**2110-9-9**] 9:59 AM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 7**] # [**Clip Number (Radiology) 71156**]
 Reason: please eval tube placement
 Admitting Diagnosis: CHOLANGITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


80 year old man just intubated


REASON FOR THIS EXAMINATION:


please eval tube placement
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh TUE [**2110-9-9**] 1:48 PM
  PFI:
  1.  ET tube 7 cm above the carina.
  2.  Improved pulmonary edema.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


80-year-old man, status post intubation, please evaluate tube
 placement.

 STUDY:  Semi-upright portable AP chest radiograph at 10:32 a.m. on [**9-9**], [**2109**].


COMPARISON:


[**2110-9-9**], 12:24 a.m.


FINDINGS:


There has been interval placement of an ET tube 7 cm above the
 carina.  A right internal jugular catheter position is unchanged in the SVC.
 The heart and mediastinal contours appear normal and unchanged from previous
 study.  The previously noted pulmonary edema appears improved.  There is a
 small amount of right lower lobe atelectasis.  There is no pleural effusion or
 pneumothorax.


IMPRESSION:


1.  ET tube 7 cm above the carina.
 2.  Improved pulmonary edema.


BS CTAB. Increased amount thick yellow secretions with temp spike to 102.4. Needs trach and PEG. Rehab screening pending following procedures. Wean PEEP by ABG's.


NPN NIGHTS


Alt in Resp Status: Received on SIMV 19/5 rate 16, this is
where he remains at this time. FiO2 mostly 21% this shift.
Has occasional drifts to the high 80's. LS coarse to clear.
Sxn q4hrs for small amounts clear secretions. RR 40's-70's.
Will check blood gas this am.

Alt in FEN: Weight 2605gm up 90 ([** 18**] notified of weight
increase). BW 2515. TF 80cc/kg/day D10 via PIV. NPO. UO
2.2cc/kg/hr x8hrs. Small mec stool x1. Small clear spits x2.
Belly benign. Will check 24hr lytes,BUN, Cr, bili, D/S this
am.

Alt in Dev: Temp stable under servo warmer. Nested with
boundaries. Awake and quietly alert at times and irritable
at others. Sleeps for 2-3hr periods of time. Will continue
to provide for developmental needs.

Alt in Parenting: Mom and dad up to visit. Updated them on
baby's evening and answered their questions. Mom [**Name (NI) 43**] upon
leaving unit. Will continue to provide support and teaching.

Alt in CV status: Received baby on 4mcg Dopamine/hr. Weaned
to 2mcg at 1015pm and shut Doapa off at 0230. BP means 38-44
off Dopa. No murmur noted. Color ruddy. Hands and feet cool
to touch at times. + pulses. HR 110-140's. Will continue to
monitor BP closely.

Potential for Sepsis: Continues on Amp and Gent. Blood cx
pending. Will continue with antibiotics as ordered.


NNP Physical Exam
Asleep. AFOF. Good tone. Breath sounds clear and equal. No audible murmue, well perfused.


Chief Complaint: Ms. [**Known lastname 7930**] is a 69 year old female with MELD 32
   EtOH cirrhosis c/b encephalopathy, ascites, portal hypertensive
   gastropathy, and grade II varices transferred to the MICU for
   encephalopathy and renal failure.
   24 Hour Events:
 TRANSTHORACIC ECHO - At [**2149-8-25**] 10:30 AM
   - goes into afib periodically. when in afib her pressure is stable, but
   when in sinus she is hypotensive
   -gave 500cc bolus and albumin today for low bp
   -tte ordered
   -pt c/o abd pain and we got KUB which showed no acute changes
   -cdiff neg
   -cultures NGTD
   -Cr continues to rise slowly
   -almost no uop and very bloody. flushed foley to confirm no clots. will
   repeat renal u/s tomorrow to confirm no obstruction
   -started on phoslo
   -run of ~20 beats NSVT s dropping pressures, resolved spontaneously, K
   and Mg appropriate and EKG s acute changes.
   Allergies:
   Sulfa (Sulfonamide Antibiotics)
   Wheezing;
   Shellfish Derived
   Anaphylaxis;
   Latex
   Rash;
   Last dose of Antibiotics:
   Ceftriaxone - [**2149-8-25**] 12:00 PM
   Infusions:
   Other ICU medications:
   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  [**2149-8-26**] 07:18 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 36.5
C (97.7
   Tcurrent: 35.8
C (96.4
   HR: 59 (49 - 95) bpm
   BP: 109/50(70) {81/41(53) - 125/70(88)} mmHg
   RR: 15 (9 - 26) insp/min
   SpO2: 97%
   Heart rhythm: SB (Sinus Bradycardia)
   Height: 66 Inch
    CVP: 24 (24 - 24)mmHg
   Total In:
                                                                  3,913 mL
                                                                    147 mL
   PO:
   TF:
                                                                    387 mL
                                                                     27 mL
   IVF:
                                                                  2,333 mL
   Blood products:
                                                                  1,004 mL
   Total out:
                                                                    868 mL
                                                                      0 mL
   Urine:
                                                                     53 mL
   NG:
                                                                     15 mL
   Stool:


Sinus rhythm
Left atrial abnormality
Early R wave progression
Consider inferoposterior myocardial infarction
Anterolateral ST-T changes suggest myocardial injury/ischemia
Since previous tracing, ST-T wave abnormalities more marked
Clinical correlation is suggested


Oliguria/Anuria
   Assessment:
   Pt
s remains oliguric, UOs 10-15ml/hr of amber/sediment urine, creat
   was 2.1 (up from 1.4), Hct was 37, adequate SBP and MAPs
   Action:
   Pt maintenance fluid increased to 150ml/hr of LR, placed subclavian
   triple lumen for IV access and to monitor CVP (CVP was initially [**11-28**]),
   given 500ml of NS bolus x1
   Response:
   UO increased to 20-25ml/hr, CVP 3-4, creat this afternoon rose to 2.7
   Plan:
   Continue to monitor UO, CVP, give IV fluid for resuscitation
   Dementia (including Alzheimer's, Multi Infarct)
   Assessment:
   Pt pleasantly confused, at times pulls at lines/tubings
   Action:
   [**Name (NI) 3320**] Pt that he is in the ICU after endovascular repair of his
   ruptured AAA, concealed lines/tubes, family at bedside for most of the
   afternoon
    Response:
   Pt able to remain calm/cooperative while on bedrest
   Plan:
   Continue to monitor for signs of increased confusion and agitation,
   ?restarting pre-op meds for Parkinson
s and dementia as Pt is able to
   tolerate PO meds and clear liquids


Chief Complaint:  GI bleed
   I saw and examined the patient, and was physically present with the ICU
   Resident for key portions of the services provided.  I agree with his /
   her note above, including assessment and plan.
   HPI:
   85 yom dementia resident of [**Hospital3 4610**] Hosp, in USOH until 1
   day PTA with the development of dark tarry stool.
   (History limited as patient unreliable historian due to dementia)
   [**Hospital1 1**] ER evaluation revealed BP= 107/53; HR= 105; RR= 24; SaO2= 93-94%
   2 L.  Abd benign, rectal with guiac + stool.  Hct= 29.9, INR= 1.2.  iv
   protonix and GI consultation obtained.  No NGT placement (as pt.
   uncooperative).  Now transferred to MICU for further evaluation and
   mangement.
   Notes mild dyspnea.  No cough, sputum. Denies abd pain, chest pain.
   Reportedly with recent hospitalization [**Hospital3 1492**] for appendicitis
 appendectomy, reportedly complicated by ARDS.
   Patient admitted from: [**Hospital1 1**] ER
   History obtained from [**Hospital 31**] Medical records
   Patient unable to provide


history:


Encephalopathy
   Allergies:
   Sulfa (Sulfonamides)
   Unknown;
   Last dose of Antibiotics:
   Infusions:
   Pantoprazole (Protonix) - 8 mg/hour
   Other ICU medications:
   Other medications:
   Past medical


history:


Family


history:


Social


History:


DEMENTIA
   COPD
   CAD s/p stent [**2169**]
   h/o V-FIB arrest
   s/p APPY
   s/p CHOLY
   H. ZOSTER right gluteal dermatome
   VRE+ (urine)
   No family  h/o GI bleed
   Occupation: Retired


Chief Complaint:
   24 Hour Events:
   - Episode of tachypnea to 40s, SBP to 80s/60 at approx 10pm, pt
   disconnected from vent and bag'ed to decreased [**Name (NI) 3819**], pt's SBP
   responded to 120's.
   - Met with Dr. [**Last Name (STitle) 161**] and in discuss with the family over the phone the pt
   was made DNR
   - Pt subsequently placed back on full pressure support and sedated,
   with subsequent pressure drop, pt then placed on NeoSynephrine and
   titrated down
   -FEVER - 102.0
 BCx, UCx, Stool sent
   Allergies:
   Codeine
   Unknown;
   Last dose of Antibiotics:
   Piperacillin/Tazobactam (Zosyn) - [**2139-10-8**] 06:00 AM
   Vancomycin - [**2139-10-9**] 12:09 AM
   Metronidazole - [**2139-10-9**] 07:57 AM
   Ciprofloxacin - [**2139-10-9**] 10:00 PM
   Infusions:
   Midazolam (Versed) - 1 mg/hour
   Fentanyl - 100 mcg/hour
   Phenylephrine - 1.5 mcg/Kg/min
   Other ICU medications:
   Lorazepam (Ativan) - [**2139-10-9**] 08:09 PM
   Morphine Sulfate - [**2139-10-9**] 08:15 PM
   Heparin Sodium (Prophylaxis) - [**2139-10-10**] 01:00 AM
   Midazolam (Versed) - [**2139-10-10**] 04:30 AM
   Fentanyl - [**2139-10-10**] 04:30 AM
   Other medications:
   Changes to medical and family


history:


No changes
   Review of systems is unchanged from admission except as noted below
   Review of systems: Unable to obtain
   Flowsheet Data as of  [**2139-10-10**] 06:13 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.9
C (102
   Tcurrent: 38.9
C (102
   HR: 150 (131 - 153) bpm
   BP: 90/65(73) {75/57(65) - 183/111(130)} mmHg
   RR: 45 (17 - 45) insp/min
   SpO2: 100%
   Heart rhythm: SVT (Supra Ventricular Tachycardia)
             Total In:
                                                                  2,841 mL
                                                                  1,402 mL
   PO:
             TF:
                                                                  1,441 mL
                                                                    373 mL
   IVF:
                                                                  1,220 mL
                                                                    898 mL
   Blood products:
   Total out:
                                                                  1,209 mL
                                                                    215 mL
   Urine:
                                                                    759 mL
                                                                    215 mL
   NG:
   Stool:


[**2141-11-16**] 8:20 PM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 31134**]
 Reason: eval for pna
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


63 year old man with Mild cardiomyopathy with ef 58%, DM, HTN, mild CAD,
  with SOB and cough productive of sputum.


REASON FOR THIS EXAMINATION:


eval for pna
 ______________________________________________________________________________


FINAL REPORT


INDICATIONS:  63-year-old man with shortness of breath and productive cough.

 CHEST, PA AND LATERAL:  Comparison is made to [**2141-11-14**].  The cardiac
 and mediastinal contours are unchanged.  There is no evidence of cardiac
 failure, but persistent vague left lower lobe opacity is again noted,
 consistent with pneumonia, as noted on the chest radiograph from 2 days
 earlier without significant change.


Mr. [**Known lastname 9611**] is an 83M with severe pancreatitis, respiratory failure, s/p
   tracheostomy on [**9-28**], PEG [**10-25**], acute on chronic renal failure and
   septic shock.  Patient is a full code.
   Sepsis, Severe (with organ dysfunction)
   Assessment:
   BP: 112-135/41-55                    HR: 59 SB- 71 SR w/rare PVC
   Action:
   Received vasopressin @ 2.4 units/hr overnight.     Continues on
   cefepime IV & tobramycin by inhalation.  Contact precautions maintained
   for resistant pseudomonas growing in sputum.  Vasopressin off 0300-0315
   until BP dropped to 102/43 w/MAP 57
   Response:
   MAP maintained>65 on vasopressin IV.  Tried to shut it off
   unsuccessfully @ 0300.
   Plan:
   Continue to attempt to titrate vasopressin down as tolerated.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   Continues on CPAP @ 40% w/  PS & 5 PEEP.   Suctioned for moderate
   amount thick white secretions w/no relief.  O2 sats: 98-100%.
   Action:
   Suctioned q 1-3 hrs for moderate amount thick white secretions.
   Response:
   ABG
s (w/am labs):
   Plan:
   Continue to wean from vent.
   Renal failure, acute (Acute renal failure, ARF)
   Assessment:
   BUN  (72)                     Cr  (2.5)                        K
   (3.9)                         HCO3:  (28)
   Action:
   IV lasix drip stopped @ 1800 per team for hypotension earlier.
   Response:
   U/o remained 14-55cc/hr  overnight.
   Plan:
   Restart IV lasix drip later this morning.
   Chest pain
   Assessment:
   Patient had no c/o chest pain.  Did c/o abdominal tightness which was
   unchanged all day.  C/o SOB @ [**2144**] w/O2 sats 98-100%  & RR 17.
   Action:
   EKG done @ [**2144**], no changes.  IV heparin D/C
ed @ 2315.  Now on sc
   heparin tid.
   Response:
   Troponin trending down.  C/o SOB thought to be anxiety per intern, Dr.
   [**Last Name (STitle) 10541**].
   Plan:
   Will check cardiac enzymes w/am labs.


CVICU
   HPI:
   58 yo M POD # 1 from emergency Asc Ao replacement (28 gelweave) AVR (27
   CE perimount tissue) for Type A dissection
   Chief complaint:
   PMHx:
   Not known
   Current medications:
   24 Hour Events:
 INTUBATION - At [**2179-10-18**] 10:45 AM
   intuabted at OSH
 OR RECEIVED - At [**2179-10-18**] 10:45 AM
 ARTERIAL LINE - START [**2179-10-18**] 10:45 AM
 CCO PAC - START [**2179-10-18**] 10:45 AM
 TRAUMA LINE - START [**2179-10-18**] 10:45 AM
 INVASIVE VENTILATION - START [**2179-10-18**] 10:45 AM
 NASAL SWAB - At [**2179-10-18**] 11:00 AM
   MRSA screen
 EKG - At [**2179-10-18**] 12:08 PM
 ULTRASOUND - At [**2179-10-18**] 07:07 PM
   renal/abd ultrasound
   Post operative day:
   POD#1 - s/p Ascending Aorta replacetment with 28 mm gelweave. AVR with
   27 mm CE tissue valve
   - Low mixed venous immediately post-op. Improved with transfusion of
   PRBC and epi gtt
   - Increased lactate, improved with volume resuscitation
   - Post volume resuscitation pt became hypertensive treated with
   hydralazine and nicardipine gtt
   - Hyperglycemic --> on insulin gtt
   - Surgical and renal consults for rising createnine
   Allergies:
   Last dose of Antibiotics:
   Cefazolin - [**2179-10-18**] 11:58 PM
   Infusions:
   Nicardipine - 2 mcg/Kg/min
   Insulin - Regular - 1 units/hour
   Other ICU medications:
   Hydralazine - [**2179-10-18**] 05:15 PM
   Sodium Bicarbonate 8.4% (Amp) - [**2179-10-18**] 05:46 PM
   Morphine Sulfate - [**2179-10-19**] 05:33 AM
   Other medications:
   Flowsheet Data as of  [**2179-10-19**] 08:35 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**82**] a.m.
   HR: 70 (67 - 105) bpm
   BP: 132/55(75) {88/32(48) - 132/71(86)} mmHg
   RR: 15 (14 - 22) insp/min
   SPO2: 91%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 68 Inch
   CVP: 24 (7 - 24) mmHg
   PAP: (36 mmHg) / (10 mmHg)
   CO/CI (Fick): (9.3 L/min) / (4 L/min/m2)
   CO/CI (CCO): (6.7 L/min) / (2.9 L/min/m2)
   SvO2: 70%
   Mixed Venous O2% sat: 46 - 65
   Total In:
                                                                 19,820 mL
                                                                    338 mL
   PO:
   Tube feeding:
   IV Fluid:
                                                                 12,114 mL
                                                                    338 mL
   Blood products:
                                                                  7,606 mL
   Total out:
                                                                  1,815 mL
                                                                  1,060 mL
   Urine:
                                                                    510 mL
                                                                    610 mL
   NG:
                                                                    300 mL
                                                                    150 mL
   Stool:


[**2134-6-9**] 2:14 PM
 UNILAT UP EXT VEINS US LEFT                                     Clip # [**Clip Number (Radiology) 43036**]
 Reason: ?DVT
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


87 year old man with L upper extremity swelling at the site of PICC


REASON FOR THIS EXAMINATION:


?DVT
 ______________________________________________________________________________
 WET READ: SZm WED [**2134-6-9**] 2:51 PM
  No upper extremity DVT.
  [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18606**]
 WET READ VERSION #1
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


87-year-old male with upper extremities swelling at the site of
 the PICC line, question of upper extremity DVT.


TECHNIQUE:


Upper extremity ultrasound

 There is normal flow, compressibility, and augmentation seen in the right
 subclavian vein, the left subclavian vein, the left internal jugular vein, the
 left axillary vein, the left brachial vein, and the left basilic vein.  The of
 the PICC line can be seen within the basilic.  Normal flow and compressibility
 is demonstrated around the PICC line.


IMPRESSION:


No left upper extremity DVT.


TITLE:
   Chief Complaint:
   24 Hour Events:
 PICC LINE - STOP [**2177-7-16**] 01:30 PM
 ARTERIAL LINE - STOP [**2177-7-16**] 03:00 PM
   - to be transferred back to [**Hospital 328**] Rehab once bed is available
   - very anxious, started on ativan prn
   Allergies:
   Codeine
   swelling;
   Tetanus
   Unknown;
   Meropenem
   Rash;
   Last dose of Antibiotics:
   Meropenem - [**2177-7-15**] 10:31 AM
   Vancomycin - [**2177-7-16**] 06:00 PM
   Cefipime - [**2177-7-17**] 05:30 AM
   Infusions:
   Other ICU medications:
   Lorazepam (Ativan) - [**2177-7-16**] 04:00 PM
   Heparin Sodium (Prophylaxis) - [**2177-7-17**] 05:30 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  [**2177-7-17**] 07:10 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.1
C (100.5
   Tcurrent: 37.2
C (98.9
   HR: 86 (75 - 97) bpm
   BP: 90/44(55) {90/33(50) - 116/60(71)} mmHg
   RR: 20 (19 - 28) insp/min
   SpO2: 93%
   Heart rhythm: 1st AV (First degree AV Block)
   Wgt (current): 150.8 kg (admission): 122.5 kg
   Height: 67 Inch
             Total In:
                                                                  2,916 mL
                                                                    808 mL
   PO:
             TF:
                                                                  1,827 mL
                                                                    466 mL
   IVF:
                                                                    484 mL
                                                                    172 mL
   Blood products:
   Total out:
                                                                  1,955 mL
                                                                    880 mL
   Urine:
                                                                  1,915 mL
                                                                    880 mL
   NG:
   Stool:


FULL CODE
   40 y/o Portuguese-speaking woman with metastatic esophageal SCC now p/w
   respiratory distress and stridor.  Admitted yesterday from clinic to
   OMED with dehydration, weakness, fever and neutropenia.  She was
   treated with antibiotics and GCSF but developed progressive stridor and
   dyspnea afternoon and evening of [**3-27**].  Seen by ENT and found to have
   immobile vocal cords with narrowed upper airway.  Treated with steroids
   and transferred to MICU.
   Here, interviewed via phone interpreter, she denied pain and complained
   only of stridor, dyspnea, and anxiety.
   PMH
          Esophageal cancer
   o         SCC
   o         Very high cervical site
   o         Currently on chemo.  S/P XRT.
   o         Complicated diagnostic pathway
   o         J tube
   o         s/p trach [**12-4**]
 [**2131-1-25**]
          sinus tachycardia (no clear etiology)
          hypercalcemia


[**2180-4-12**] 10:47 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 81629**]
 Reason: EValuate for ICH/mass
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


65 year old man with fever and confusion, ? loss of continence


REASON FOR THIS EXAMINATION:


EValuate for ICH/mass
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


65-year-old male with fever and confusion, and questionable loss
 of continence.  Please evaluate for ICH or mass.


COMPARISON:


[**2179-2-9**], and MRI from [**2179-2-24**].


TECHNIQUE:


Non-contrast head CT.


FINDINGS:


The study is slightly limited by motion.  There is no evidence of
 hemorrhage, edema, mass, mass effect, or acute vascular territorial
 infarction.  The ventricles are normal, and unchanged in size and
 configuration.  Small hypodensities are seen in the left subinsular
 region as well as the frontal lobes bilaterally as before which likely
 represent microangiopathic change.  Slight extraaxial CSF prominence over the
 left temporal lobe is unchanged, of uncertain significance.  Note is again
 made of numerous punctate subarachnoid hyperdensities, unchanged in size and
 configuration. These may reflect vascular calcifications versus dystrophic
 calcification from prior infection or inflammation.

 There is no fracture.  Visualized paranasal sinuses are normally aerated.


IMPRESSION:


1.  No acute intracranial process.
 2.  Unchanged extraaxial CSF prominence in the left temporal lobe.
 3.  Unchanged punctate subarachnoid calcifications, possibly representing
 vascular calcification versus dystrophic calcification from prior infection or
 inflammation.


focus; addendum
RESP- AT 1800 PATIENT REQUESTED TO BE SUCTIONED. SHE WAS SUCTIONED FOR APROXIMATELY 20CC OF FRANK BLOOD. DR [**Last Name (STitle) 11211**] NOTIFIED. STAT HCT ORDERED THAT WAS 28 WHICH IS STABLE FOR THE PATIENT. PATIENT ANXIOUS. 0.5MG ATIVAN GIVEN. PS INCREASED TO 10 AND FIO2 INCREASED TO 50% FROM 40 PER RESP AS SAT ON 40% DOWN TO 89%. CXR TO BE DONE.


HPI:
   68 yo F of unclear handedness with hx HTN, HLD, NIDDM, DVT, CRI,
   metastatic endometrial CA to lung, s/p 2nd cycle [**Doctor Last Name 1793**]/taxol, and
   congenital L sided hypoplasia, presents after acting "disoriented" as
   per patient's son, now with new parenchymal hemorrhage, possibly
   hemorrhagic transformation of subacute strokes and possible
   subarachnoid hemorrhage after unwitnessed fall on lovenox and platelet
   count of 39 and likely head trauma.
   Chief complaint:
   fall
   PMHx:
   PMHx;
   HTN  HLD  NIDDM  DVT  metastatic endometrial CA, on taxo/carboplatin
   2nd cycle  IVC filter  CRI
   Hypotension (not Shock)
   Assessment:
   Patient  b/p labile via femoral a-line running from 60
s over 40
s to
   100
s over 50
s, heart rate 100-120
s sinus tachycardia.
   Action:
   Patient started on 3  pressors Vasopressin, Neosephrine, levophed. 1
   liter normal saline bolus
   Response:
   Patient
s pressures continue to be very labile titrating drips
   accordingly.
   Plan:
   Continue with support Notify team of any changes.
   Intracerebral hemorrhage (ICH)
   Assessment:
   Patient intubated on fentanyl neuro exam waxes and wanes does not
   follow commands, does not open eyes to stimuli, pupils sluggish 3mm,
   withdraws to painful stimuli on right does not respond on left side to
   noxious stimuli.
   Action:
   Continue with q 1 neuro exams.
   Response:
   Patient neuro exam worsening throughout shift patient pupils
   unresponsive and right side not moving with noxious stimuli.
   Plan:
   Family meeting with team to discuss code status Continue to notify team
   of any changes. Provide comfort and support.
   Neuro med resident spoke with son twice about mother
s grave condition
   son did not want to come in to see patient and wants mother to remain a
   full code even though condition has detiorated.


PATIENT/TEST INFORMATION:


Indication:


hypotension.  Re-evaluate LV
Height: (in) 68
Weight (lb): 249
BSA (m2): 2.25 m2
BP (mm Hg): 105/54
HR (bpm): 99
Status: Inpatient
Date/Time: [**2193-3-12**] at 11:58
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Suboptimal


INTERPRETATION:


Findings:


LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severely
depressed LVEF. Estimated cardiac index is borderline low (2.0-2.5L/min/m2).
No resting LVOT gradient.

LV WALL MOTION: Regional LV wall motion abnormalities include: basal
anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal -
akinetic; mid inferoseptal - akinetic; basal inferior - hypo; mid inferior -
hypo; basal inferolateral - hypo; mid inferolateral - hypo; septal apex -
hypo; inferior apex - hypo;

RIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function
depressed.

AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.
Normal ascending aorta diameter. Focal calcifications in ascending aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral
annular calcification. Mild thickening of mitral valve chordae. Calcified tips
of papillary muscles. No MS. Mild to moderate ([**2-2**]+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal
tricuspid valve supporting structures. No TS. Mild PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.
Physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal
image quality - poor apical views. Suboptimal image quality - body habitus.

Conclusions:
The left atrium is mildly dilated. The right atrium is markedly dilated. There
is mild symmetric left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 20-30 %) secondary to akinesis of the interventricular septu,
and hypokinesis of the inferior and posterior walls. The right ventricular
cavity is dilated with depressed free wall contractility. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened; there is mild-to-moderate
mitral regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed) of [**2193-3-10**], the left ventricular ejection fraction is further reduced.


.H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &
   FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE
   (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,
   HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS
   Seizure, without status epilepticus
   Assessment:
   Pt. has not had any seizure activity recently. Continues on Kepra.
   Neurologically, pt is intact. He states he is more awake and clear
   today than recently. MAE, appropriate and cooperative. Pupils are not
   equal, this is well documented since arrival (this admission). Pt. is
   alert and oriented with slight coaching  needed on place, may say he is
   at
[**Hospital 1165**] Hosp
 or [**Hospital1 **]. Denies pain,
never had any pain
   Action:
   Continues on Kepra. Monitor neuron signs as odered.
   Response:
   Stable neuro signs, intact. No seizure activity.
   Plan:
   Cont. to monitor. Cont Kepra
   Bradycardia
   Assessment:
   HR presently in the 80
s, sinus, no ectopy noted. External pacer pads
   remain in place. Per SICU team, lopressor 25mg po was dc
d this am and
   pt. was increased on hydralazine prn, 20mg q 6 hr as needed. SBP 140
   160
s, goal to keep below 160.
   Action:
    Given hydralazine 20 mg x 1  Monitored HR for changes.
   Response:
   HR remains stable, rate in the 80
s, sinus. SBP dropped to 130
s-140
   with hydralazine prn.
   Plan:
   Continue to monitor HR and BP. Meds as needed to keep SBP below 160.
   Maintain pacer pads to externally pace pt. if HR drops down. Cardiology
   to f/u on rhythm issues.
   Peripheral vascular disease (PVD) without critical limb ischemia
   Assessment:
   Pt. has peripheral edema to both legs (and arms). Legs are warm with
   peripheral pulses faintly palpable and easily dopplerable. Legs are
   both red in the calves, swelling as well. Brisk blanching of toes. Pt.
   is able to move legs around in bed without too much difficulty, he has
   not been out of bed as yet.
   Action:
   Monitor circulation to legs.
   Response:
   Adequate pulses to feet, warm
   Plan:
   Continue to monitor circulation to feet.


NICU NURSING PROGRESS NOTE:

FEN.O: Weight=2.020kg, ^50gm. [**Known lastname 1735**] TF is decreased to
140cc/k/d of BM 24+neosure powder, 47cc Q4 hrs. PO/PG
feeding. Offerred bottle, taking [**1-17**] of required before
tiring. Remainder suplemented by gavaged. Abd exam is soft
but full, no loops. BS active. Voiding and stooling. No
spits, large aspirates 8.3cc. Abd girth is 28cm.
A: Baby is gaining weight.
P: Continue to encourage PO feeding and support feeding
plan.
G/D.O: [**Known lastname 1732**] is swaddled in open crib with his twin brother.
Active and [**Name2 (NI) 96**] with cares. Waking for feeds every 3.5-4
hrs. Sleeps well between cares. Sucks on pacifier.
A: AGA. P: Continue to support developmentally.

Parenting: [**Name2 (NI) 14**] stayed in for the 8:30pm feeding. Updated
regarding [**Known lastname 1735**] weight and plan of care by RN [**Doctor First Name 255**] and
myself. Dad bottled and he took only 16cc for his dad.
[**Name (NI) 14**] are indepen with cares. Loving and caring family.
P; Continue to support.


[**2144-1-3**] 5:48 PM
 CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN                      [**Name Initial (PRE) 26**] # [**Clip Number (Radiology) 34054**]
 Reason: pls eval for ptx
 Admitting Diagnosis: AORTIC ANEURYSM
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


59 M s/p placement of right IJ


REASON FOR THIS EXAMINATION:


pls eval for ptx
 ______________________________________________________________________________
 WET READ: MLHh FRI [**2144-1-3**] 8:11 PM
  R IJ line in mid SVC.  No PTX.  Persistent severe cardiomegaly, venous
  congestion, pulm edema, mod L/sml R effusions.  LLL opacity (atelectasis +/-
  consolidation).
 ______________________________________________________________________________


FINAL REPORT


CHEST RADIOGRAPH


INDICATION:


Right internal jugular vein catheter, evaluation for
 pneumothorax.


COMPARISON:


[**2144-1-3**].


FINDINGS:


The newly placed right internal jugular vein catheter is projecting
 over the mid SVC with its tip.  There is no evidence of complications, notably
 no pneumothorax.  Persistent severe cardiomegaly with moderate-to-severe
 pulmonary edema, accompanied by bilateral pleural effusions.  The retrocardiac
 atelectasis is unchanged.


Nursing Progress Note.
(Continued)
 Please apply multiple dry sterile 4X4's above this wound packing and affix in place c paper tape.

FAMILY: No visitors or calls received for this pt today.  The pt is a full code.

OTHER: Please see CareVue for additional pt care data/comments.


ekg nsr, no ectopy, rate 70s.  abp stable, no hydralazine given overnight.  lowgrade temp, 100.3.  breath sounds coarse to clear after suctioning, on trach mask all night.  suctioned freq for mod to large amts thick tan secretions, vomited x 1 when suctioned, was being ambued by resp rx at the time, no evidence of aspiration into trach.  abd soft, tolerating tf at 90cc/hr via peg.  mod soft stool x 1.  opens eyes spont and to voice, moves l side spnt and to command with normal strength, r side moves only when withdrawing from noxious stimuli or during cough, then leg and arm move grossly.  did see knee bend and toes wiggle to tickle bottom of foot.  nods approp to yes/no questions,  denied pain, when asked if he could mouth words, nodded yes, but was unable to do it.  left wrist immobilized due to pulling at trach and foley when loose.  plan: pulm toilet, monitor vs, osm, continue to wean mannitol, contnue tf, to rehab when approp.


[**2191-6-16**] 12:28 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 116668**]
 Reason: FAST TRACK EXTUBATION CARDIAC SURGERY PROTOCOL, ?line placem
 Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


58 year old man with CAD s/p CABG. Please [**First Name8 (NamePattern2) 458**] [**First Name4 (NamePattern1) 1824**] [**Last Name (NamePattern1) 1825**] at [**Numeric Identifier 3793**] with
  abnormalities.


REASON FOR THIS EXAMINATION:


FAST TRACK EXTUBATION CARDIAC SURGERY PROTOCOL, ?line placement, r/o
  PTX/Effusion
 ______________________________________________________________________________


FINAL REPORT


STUDY:  Chest radiograph.


INDICATION:


Patient with CAD status post CABG, fast track extubation program,
 for evaluation.


TECHNIQUE:


PA radiograph was obtained.


COMPARISON:


[**2191-5-27**].

 REPORT:

 ET tube remains in good position.  NG tube courses through the mediastinum and
 terminates in its expected location of the stomach.  Right-sided chest tube is
 identified.  The patient is status post sternotomy.  Likely also LIMA
 grafting.  No evidence of pneumothorax.  Mediastinal drains are identified in
 situ.  No definitive acute cardiopulmonary findings.

 Right-sided central line with tip is in the proximal SVC.

 CONCLUSION:

 No definitive acute findings or evidence of pneumothorax.  Support hardware
 appears in satisfactory position.


Nursing progress Note:  7p-7a

Pateint admitted from ER on the [**9-7**] with Exacerbation of asthma secondary to LLL PNA.  Was seen in Er earlier that day and was sent home on Levoquin po.  Returned later that day by EMS in resp distress and intubated, sent to MICU for further management.  Admission to ICu was complicated bt a an upper GI bleed that was caused by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3598**] [**Last Name (NamePattern1) **] tear from coughing and in addition to hialtal hernia.  Was given 2 units PRBC's and had a bedside EGD. Plan to fully sedate patient to avoid emesis and couging so tear can heal. Patient does have influenza A and asthma is very severe with MDI's qhourly on high vent support.  She also has RLL collapse and ocluded RLL bronchus.

Overnight patient remained stable.  Dopamine was weaned off andf patinet maintained MAP>60 and BP95-100 sys. Required NS bolus at 0200 for low urine output. See carevue for details.

Neuro: Sedated On Fent 25 and Versed 2.  Is arousable to voice and tactile stimutation moving all extremities appropriatly. Not obeying commands. To sedate to aviod wretching and coughing in order to aviod the clot at the junction of esophagus and stomach.

CV:  Dopa off since 0100.  and is tolerating as mentioned above. In NSR, no Ectopy. Serial HCT have decreased...last one at 0400 bloods 39.6, down from 41.6 at MN. Goal to keep HCT>30. still awaiting chemistry.  CK 233, -MB. WBC normal.  Continues on Levo IV. CVP 9-11. Afebrile

RESP:  Continues on same vent setting and is doing well. AC X 20/550/40%?Peep 12. ABG: 7.39/36/169. Lungs I and E wheezes and getting q2combivent and q1albuterol. suctioned X1 by RT, but did not get sample. Auto peep at 2-4 cm.

GU:  Foley draining well but urine output dropped after dopa weaned off even bp and CVP adequate.  Bolused with NS 500 ml and it picked up to 30-40/hr.  Dr [**Last Name (STitle) **] made aware and not further management at present. +7446 for last 24 hours and + 360 since MN


GI:  No obvious signs of bleeding, no emesis. continues on protonix, no feeding tube till tear healed. Will be seen by GI daily. on Insulin 1 unit all night, Sugars 90-100.

Skin intact

Plan: follow HCT
      monitor for bleeding.
      avoid coughing and wretching with adequte sedation.
      ? bronch after tear healed to assess RLL collapse
      solumedrol and abx
      follow abg
      fluid for hypotension and low urine output


RESP CARE
40 YO WOMAN RECEIVED INTUBATED FROM OSH S/P OD SZS SUICIDE ATTEMPT. H/O OF SUICIDE ATTEMPTS AND IV/ POLYSUBSTANCE ABUSE.
BS: COARSE RHONCHI ON THE RIGHT LEFT CLEAR , ?ASPIRATION
ABG: RESP. ACIDOSIS WITH MARGINAL OXYGENATION.
PLAN: CONTINUE TO SUPPORT.


CLinical Nutrition
O:
~30 [**1-4**] wk CGA BB on DOL 16.
Wt:  1275 g (+30)(~25th %Ile); birthwt:  1275 g.  Average wt gain over past wk ~16 g/kg/day.
HC:  27.5 cm(~25th %Ile); last: 26 cm
LN:  39 cm (~25th to 50th %Ile); last:  38.5 cm
Meds include Fe and Vit E
[**Month/Day (2) 107**] not due yet
Nutrition:  130 cc/kg/day BM 28 w3/ beneprotein, all pg over 60 min feeds due to hx of spits and bradys w/ feeds, ?of reflux.  Projected intake for next 24hrs ~121 kcal/kg/day and ~3.6 g pro/kg/day.
GI: Abdomen benign.

A/Goals:
Tolerating feeds over extended feeding times without GI problems.  [**Name (NI) 107**] not due yet.  Current feeds + supps meeting recs  for kcals/pro/vits and mins.  Growth is meeting recs for wt gain.  HC gain is exceeding recommended ~0.5 to 1 cm/wk; represents catch up growth.  LN gain is not meeting recommended 1 cm/wk; will follow long term trends for linear growth.  Will continue to follow w/team and participate in nutrition plans.


MICU Nursing Progress Note 7am-7pm
See Carevue for Additional Objective Data
#1:Infection; Klebsiella UTI
D:Tmax:102 rectal, receiving tylenol PR RTC, cooling blanket on most of the day. WBC:40 Pan cx [**12-20**]:png. Antibx unchanged. ABD U/S:negative
  MS:Alert but confused, thought she was "in the dungeon" and that she was "a terrible baby" becoming increasing paranoid over the coarse of the afternoon.
  HR:tachycardic as high as 158 ST with fever 102, BP:85-120/ higher when receiving NS fluid boluses K:3.5 post 60 meq repletion
  U/O:140-300cc/hr I/O's from midnoc:3500cc+ Urine clear yellow urine
  Denies SOB; intermittent tachypnea associated with stimulation RR:26-44/min BS:clear, diminished at bases. No cough, no sputum production. Raised some thick tan oral secreations from back of mouth.

A:Antipsychotic medications remain on hold;continues to receive Klonopin TID
  Tylenol PR RTC
  60meq KCL Repletion started at 17:00
  U/A sent to evaluate brisk U/O

R:Responds very well to Klonopin, recognized mother, less paranoia, thoughts more coherent, Tylenol RTC with cooling blanket held T:101 for most of the day. Cont to evaluate fluid status, cont with supportive care as previously documented


[**2132-11-3**] 6:11 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 72751**]
 Reason: ? ptx after CT removal
 Admitting Diagnosis: INFECTED INTERNAL CARDIOVERTER DEFIBRILLATOR\ICD GENERATOR CHANGE; LEAD EXTRACTION/SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


35 year old man with pacer lead removal/sepsis. s/p CPB for removal, familial
  dilated CM


REASON FOR THIS EXAMINATION:


? ptx after CT removal
 ______________________________________________________________________________
 WET READ: SPfc MON [**2132-11-3**] 6:51 PM
  A mediastinal drain has been removed.  Now evidence of
  pneumothorax/pneumomediastinum.  A tubular density projecting from caudal to
  the field of view and terminating over the left hilar region of the previous
  study has now been retracted.  Otherwise, minimal change with stable
  cardiomegaly and bilateral pleural effusions.
 ______________________________________________________________________________


FINAL REPORT


AP CHEST, 6:22 P.M., [**2132-11-3**]:


HISTORY:


A 35-year-old man.  Pacer lead removed.  Sepsis.  Cardiomyopathy.
 Question pneumothorax.


IMPRESSION:


AP chest compared to [**10-31**] and 10:

 There is a suggestion of a gas collection or soft tissue defect in the left
 anterior chest wall where surgical sponge markers were noted on [**10-31**],
 since removed.  Severe enlargement of the cardiac silhouette has worsened, but
 pulmonary edema has improved.  Small right and small-to-moderate left pleural
 effusion persists, but most of the opacification at the left lung base is due
 to consolidated left lower lobe, either collapsed or pneumonia.  Mediastinal
 vascular congestion indicates elevated central venous pressure or volume.
 Pericardial effusion would need to be excluded by other means, if not already
 done so.  Tip of the ET tube is at the upper margin of the clavicles, no less
 than 6 cm from the carina, 2 cm above optimal placement if the chin is in
 neutral position, acceptable if the chin was elevated.  An ascending central
 venous line ends in the right ventricle.  The remnants of right ventricular
 pacer and pacer defibrillator leads are unchanged in their respective
 positions.  No pneumothorax.


Subjective:
   Objective:
   Follow up PT visit to address goals of: [**2121-7-18**]. Patient seen today
   for patient education
   Updated medical status: CXR [**7-21**] pnd
   Activity
   Clarification
   I
   S
   CG
   Min
   Mod
   Max
   Rolling:
                                      T




   Supine/
   Sidelying to Sit:

                                      T



   Transfer:

                                      T



   Sit to Stand:

                                      x
                                      x


   Ambulation:





   Stairs:





   Aerobic Activity Response:
   Position
   HR
   BP
   RR
   O[2] sat
   RPE
   Rest
   Supine
   100
   118/74
   98% on 4L
   Activity
   Sit
   130
   122/72
   96% on 2L
   Recovery
   Sit
   106
   /
   96% on 2L
   Total distance walked: 2'
   Minutes:
   Gait: little unsteady pushing w/c, declined further ambulation and
   transferred to chair.
   Balance: S static sitting, CG static/dynamic standing balance.  No
   gross LOB with mobility.
   Education / Communication: Reviewed PT [**Name (NI) **] and encouraged OOB.
   Communicated with nsg re:status.
   Other: Limited by c/o pain at foley insertion site, also c/o [**10-18**]
   abdominal pain.
   Increased R foot inversion with mobility, no AFO.
   Assessment: 60 yo M with suicidal ideation making minimal progress in
   PT, recently admitted to icu with coffee-ground emesis and awaiting
   EGD.  He is below his baseline level, will reassess mobility after
   transfer from icu.  Continue to anticipate d/c home when medically
   appropriate.
   Anticipated Discharge: Home without PT
   [**Name (NI) 440**]: continue with [**Name (NI) **]


Sinus rhythm. First degree A-V block. Q waves in leads VI-V3 suggestive of old
anterior myocardial infarction. Q waves in leads III and aVF suggest prior
inferior wall myocardial infarction. There are inferolateral ST-T wave
abnormalities which are non-specific. Compared to the previous tracing
of [**2151-5-21**] no significant diagnostic change.


Recieving 2nd unit RBCs for HCT of 19.  Pt had BM, mod soft brown - heme neg!

Taking po - cranberry/apple juice thickened sitting at 90 degrees and tilting chin to neck - to very well!  No coughing/gagging.


[**2142-7-19**] 10:55 AM
 ABDOMEN U.S. (COMPLETE STUDY) PORT                              Clip # [**Clip Number (Radiology) 95422**]
 Reason: ? ascites
 Admitting Diagnosis: CIRRHOSIS
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Liver failure, encephalopathy, [**Clip Number (Radiology) 95418**], now with fevers.
 Evaluate for ascites, for DVT or obstruction.  Possible hepatorenal syndrome.


COMPARISON:


Abdomen ultrasound of [**2142-7-15**].

 ABDOMEN ULTRASOUND:  A limited abdominal ultrasound was performed.  The liver
 demonstrates a coarsened echotexture and nodular contour, consistent with the
 given history of cirrhosis.  The liver was not examined in its entirety for
 focal lesions today.  There is no intrahepatic biliary ductal dilation. The
 main portal vein is patent, with completely reversed or hepatofugal flow. This
 is new from the prior study when the flow in the main portal vein was to and
 fro.  There is increased sludge within the gallbladder, which is now nearly
 full of sludge.  The common duct is not dilated, measuring 5 mm.  The right
 kidney measures 14.2 cm.  The left kidney measures 12.5 cm.  There is no
 hydronephrosis, stone or renal mass visualized.  The pancreas is not well seen
 due to overlying bowel gas.  The spleen is large, measuring 20.3 cm.  Varicose
 vessels are seen near the spleen.

 There is a very small amount of ascites fluid, with a minimal amount seen
 within each lower quadrant and slightly more fluid at the periphery of the
 cirrhotic liver.

 BILATERAL LOWER EXTREMITY ULTRASOUND:  The examination of the lower
 extremities is limited due to patient body habitus.  Grayscale and Doppler
 son[**Name (NI) 948**] of the right and left common femoral, superficial femoral, and
 popliteal veins were performed.  Normal flow, augmentation, compressibility
 and waveforms are demonstrated on this limited exam.  No intraluminal thrombus
 is identified.


IMPRESSION:


1.  Cirrhotic liver, with now completely reversed or hepatofugal flow within
 the main portal vein.  On the prior study, flow within the main portal vein
 was to and fro.  The portal vein branches were not well visualized.

 2.  Sludge filled gallbladder.

 3.  A very small amount of ascites, greatest surrounding the cirrhotic liver
 and minimal within both lower quadrants.

 4.  Splenomegaly with varices seen near the splenic hilum.

 5.  No hydronephrosis.

 6.  No evidence of DVT in either lower extremity on the limited study.

                                                             (Over)

 [**2142-7-19**] 10:55 AM
 ABDOMEN U.S. (COMPLETE STUDY) PORT                              Clip # [**Clip Number (Radiology) 95422**]
 Reason: ? ascites
 Admitting Diagnosis: CIRRHOSIS
 ______________________________________________________________________________


FINAL REPORT


(Cont)


[**2138-8-14**] 5:47 PM
 CT ABD & PELVIS W/O CONTRAST                                    Clip # [**Clip Number (Radiology) 8514**]
 Reason: sbo? other acute pathology
 Field of view: 42
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


69 year old man with ARF wtih vomtiing x24 hours


REASON FOR THIS EXAMINATION:


sbo? other acute pathology
 CONTRAINDICATIONS for IV CONTRAST:
  renal failure
 ______________________________________________________________________________
 WET READ: [**First Name9 (NamePattern2) 2895**] [**Doctor First Name 137**] [**2138-8-14**] 10:35 PM
  No SBO
  Fecal loading throughout colon and rectum
  Moderate left pleural effusion
  Normal appendix.

  Infrarenal AAA measuring 3.3 cm in transverse diameter - no signs of rupture.
  Prior kyphoplasty at L1 and L2.
 WET READ VERSION #1
 WET READ VERSION #2 [**First Name9 (NamePattern2) 2895**] [**Doctor First Name 137**] [**2138-8-14**] 9:35 PM
  No SBO
  Fecal loading throughout colon and rectum
  Moderate right pleural effusion
  Normal appendix.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


69-year-old male with acute renal failure and vomiting x 24 hours.


COMPARISON:


None available in the [**Hospital1 51**] system.


TECHNIQUE:


64 MDCT-acquired axial images from the lung bases to the pubic
 symphysis were displayed with 5-mm slice thickness.  No intravenous contrast
 was administered.  Oral contrast was given.  Coronal and sagittal reformations
 were prepared.

 CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST:  A moderate left pleural effusion
 with associated compressive atelectasis is noted.  Minimal dependent
 atelectasis is also identified at the right base.  There is no focal
 consolidation, nodule, or mass.  The visualized heart is mildly enlarged.
 Pacemaker wires are incompletely imaged.

 Complete evaluation of the abdominal viscera is limited due to the
 non-contrast technique.  However, the liver, spleen, and gallbladder appear
 within normal limits.  The adrenal glands appear bulky bilaterally, but no
 discrete nodule is identified.  No intra- or extra-hepatic biliary ductal
 dilatation is identified.  Coarse calcifications are identified within the
 pancreatic head, which is otherwise normal.  The small bowel is normal in
 caliber and configuration without evidence of obstruction or inflammation.  A
 nasogastric catheter is identified within the stomach. The appendix appears
 normal. The kidneys appear normal without evidence of hydronephrosis or
 definite focal mass.  Dense atherosclerotic calcifications are seen through
                                                             (Over)

 [**2138-8-14**] 5:47 PM
 CT ABD & PELVIS W/O CONTRAST                                    Clip # [**Clip Number (Radiology) 8514**]
 Reason: sbo? other acute pathology
 Field of view: 42
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 the abdominal aorta and its branch vessels.  The infrarenal abdominal aorta is
 mildly aneurysmal measuring 3.3 cm in transverse diameter (601B:33).  There is
 no free fluid or free air.

 CT PELVIS WITHOUT INTRAVENOUS CONTRAST:  There is significant fecal loading
 within the colon, which otherwise demonstrates no evidence of obstruction or
 inflammation.  Circumferential wall thickening of the bladder may be secondary
 to incomplete distension, though correlation with clinical status is
 recommended.  The prostate and seminal vesicles are unremarkable.  Incidental
 note is made of a calcified vas deferens.  There is no pelvic free fluid.

 OSSEOUS STRUCTURES:  No bone destructive lesion or acute fracture is
 identified.  There is evidence of prior kyphoplasty at L1 and L2.


IMPRESSION:


1.  No small bowel obstruction.
 2.  Significant fecal loading throughout the colon, though no evidence of
 large bowel obstruction or inflammation.
 3.  Moderate left pleural effusion and associated compressive atelectasis.
 4.  Mild aneurysmal dilatation of the infrarenal abdominal aorta measuring 3.3
 cm in transverse diameter.
 5.  Apparent circumferential wall thickening of the bladder may be secondary
 to incomplete distension, though correlation with urinalysis is recommended to
 exclude infection.


MICU Nursing progress note 0700-1900
CV: NSR/ST, no ectopy noted. HR 85-120. ABP 91-118/49-61. MAP's 63-71. CVP 20-23 not corrected for PEEP 18. DP's palpable. Given 1L NS bolus to increase MAP's.

Resp: Intubated, vent AC 34/450/80%/PEEP 18. ABG 7.18/71/66/28. Not breathing over vent. LS-coarse throughout.  O2 sats 88-95%. Suctioning small amts of thick tan secretions. Attempted turn on R side (swimmers position) w/o improvement in o2 sats. On triadyne bed, turning on each side 10 degrees for 2min-BP maintaining.

Neuro: Sedation-fentanyl 400mcg/hr, versed 8mg/hr, and cisatracurium 0.15mg/kg/hr (increased from 0.1 d/t coughing during suctioning). Train of four [**4-12**]. Not moving extremities. Not following commands. PERRL- sluggish.

ID: Temp 101.3 rectal. WBC 20.9. Continues on levoquin. Vanco/ceftriaxone d/c'd. Cooling blanket on. Tylenol 650mg PR given, temp trending down slowly.

GI/GU: Abd-obese. Absent BS. No BM. OGT to suction d/t residuals 160-180cc. Continues on TPN. FS-WNL. Foley-amber/clear. Output 80-120cc/hr.

Skin: Intact. On rotation bed.

Social: Sister and mother in to visit. Updated on POC.

Plan: Monitor temp curve. Monitor ABG q2hrs as needed. Suction as needed. Rotate as tolerated. Continue sedation, wean as tolerated. Routine ICU care. Emotional support for family.


PATIENT/TEST INFORMATION:


Indication:


Left ventricular function.  Pericardial effusion.
Height: (in) 69
Weight (lb): 150
BSA (m2): 1.83 m2
BP (mm Hg): 114/80
HR (bpm): 104
Status: Inpatient
Date/Time: [**2196-12-19**] at 11:36
Test: TTE (Complete)
Doppler: Complete pulse and color flow
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: The left atrium is elongated.

RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.

LEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction.

AORTA: The aortic root is normal in diameter. The ascending aorta is normal in
diameter.

AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. There is no aortic valve stenosis.

MITRAL VALVE: The mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral valve.

TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial
tricuspid regurgitation. There is no mass or vegetation detected on the
tricuspid valve.

PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear
structurally normal with physiologic pulmonic regurgitation.

PERICARDIUM: There is no pericardial effusion.

Conclusions:
Patient tachycardic. The left atrium and the right atrium are elongated and
suture lines are seen within the atria. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular systolic
dysfunction (ejection fraction 50%). There is mild hypokinesis of the inferior
septum. The right ventricular is not well visualized. The aortic valve
leaflets (3) appear structurally normal with good leaflet excursion and no
aortic regurgitation. No masses or vegetations are seen on the aortic valve.
There is no aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation is seen on the
mitral valve. There is no pericardial effusion.

Compared to the study from [**2196-11-29**] there have been no signficicant changes.


NPN  1900-0700
Pt had CTs of head/chest/pelvis on [**7-16**].  No change in head CT.  Only finding in lungs of RLL infiltrate, probably pna.  Pt's sputum was MRSA+, started on vanco again last evening.  Remainder of CTs, no change.

Neuro:  Pt not following commands.  Apparently family notes change in MS [**First Name (Titles) 206**] [**Last Name (Titles) **].  Pt moving LUE in jerking movements along with some movements of head.  Not moving arm during sleep.  Moves LLE on bed.  R side hemiparesis, flaccid.  Eyelids freq flutter.  Ativan 2mg iv given x2 for agitation.  Slept well for ~ 4-5 hrs.

CV:  HR low 100s, st, no ectopy.  SBP 108-189, lower BPs during sleep.  High BP reduced after Ativan.

Resp:  LS clear/ coarse.  Sx infreq for sm-mod amt, thick, white sputum, sx when pt coughed.  No vent changes, cont on AC 40% 400x14, Peep 5.  Overbreathing vent by up to 5.  Sats 99-100.  Trach care done.

ID:  Tmax 100.3, tylenol given c good effect.  Contact [**Name (NI) 207**] cont for MRSA.  Pt neg for C-diff.

GI:  +BS, abd soft.  Tol TF well, 40mls Pulm nutren.  Flexiseal fell out, replaced.  Cont to occ leak around it, but collecting lge amt golden brown liq stool.  ( increased vol after baracat).

GU:  Foley removed and replaced [**Name8 (MD) **] MD due to fungal infection.  Adequate u/o >30mls/hr, clear yellow urine.

Skin:  Coccyx and perineal area cont red, yeast appearing.  Antifungal ointment and pwdr applied.

Endo:  FS 195, no insulin required.

Plan:  Monitor neuro status, MS changes.  Freq skin care in perineal area, assure flexiseal in place.  Monitor VS, ? change to PSV in am.  Sx prn.


Chief Complaint:  s/p ex-lap
   HPI:
   73 yo M with PMHx significant for CAD, Infrarenal AAA s/p EVAR [**2159-12-30**],
   and bladder ca s/p radical cystoprostatectomy and ileal loop urinary
   diversion [**2160-1-22**] who presents from an OSH with abd pain and partial
   SBO. Pt notes that his most recent hospital course was complicated by a
   post op ileus that had resolved with NG tube placement. Pt was
   discharged on [**2-2**] and notes that he had not been feeling badly but was
   not feeling well overall at the time of discharge. He noted extremely
   poor appetite and had poor intake. He denied nausea and vomiting as
   well as fever. On [**2-10**], pt noted extreme diffuse abd pain and dialed
   911 and was taken to [**Hospital 327**] Hospital. At this time he reported fever
   to 102. Imaging at this time showed multiple dilated loops of small
   bowel with question of high grade, possibly partial SBO. He had an NG
   tube placed for decompression and was transferred to [**Hospital1 1**] for further
   evaluation and treatment.
   On admission, pt had low grade temp of 99.7. He had repeat abd plain
   film confirming partial SBO. Surgery was consulted and recommended pt
   remain NPO and treated with NGT and IVF. On [**2-14**] he was started on TPN
   but was noted to be spiking daily fevers. On [**2-15**] he underwent an
   abd/pelvis CT and was found to have a new pelvic fluid collection. CT
   guided drainage was performed with placement of two drains.  Cultures
   were positive for VRE and urine cultures were positive for sensitive
   enterococcus.  Last night noted to have a fever, and white count
   increasing to 24.  Urology and general surgery took him back to the OR
   for an ex-lap with washout of the abscess.  500cc of purulent fluid,
   though to be an infected lymphocele was removed, and sent for gram
   stain and culture.  Patient arrived from the OR, intubated, sedated and
   paralyzed.   Patient had not been extubated, as he remained paralyzed
   despite reversal in the OR.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 2**])
   Assessment:
   Returned to [**Location **] from or s/p exploratory lap intubated. Sedated overnoc
   on propofol gtt . vent settings with minimal support. Lungs essentially
   clear on auscultation but diminished at the bases. Rsbi this am=22 and
   pt tolerated sbt with audible air leak.
   Action:
   Resp status monitored closely and pt tolerated sbt trial. Propofol gtt
   d/c
d and pt awake and able to follow simple commands appropriately. Pt
   successfully extubated at 0800 and initially placed on 35% open face
   tent.
   Response:
   Stable resp status and now on 2l/m nc with rr in the high teens to low
   20
s and o2 sats> 99%.
   Plan:
   Continue to follow pt
s resp status and wean o2 as tolerated.
   .H/O small bowel obstruction (Intestinal obstruction, SBO, including
   intussusception, adhesions)
   Assessment:
   s/p exp lap with drainage of abscess on [**2-19**]. wbc decreased today and
   max temp=100.6 orally. Abd soft and  pt denies incisional pain. Ngt to
   low continuous suction draining sm amts of bilious drainage. per
   urology  a section of bowel was trapped between loculated fluid
   collections and it is  thought that this may be the cause of his sbo.
   Hopefully  with the collection of fluid drained  the sbo will resolve.
   Midline abd incisional drsg d&I with sm amt of serous drainage. R upper
   abdominal precutaneous [**Month/Day (2) **] with no output. Penrose [**Month/Day (2) **] with ostomy
   appliance with sanguinous drainage. Hourly uo adequate via
   illeoconduit.
   Action:
    Pt receiving d5
 ms at 125cc
s/hr. surgical drsg [**Name5 (PTitle) 43**] [**Name5 (PTitle) **] output
   monitored closely. Pain level assessed throughout the day.  Ostomy
   clinical specialist called to assist in obtaining illeostomy  bag for
   illeoconduit. Pt receiving meropenem and linezolid for antibiotic
   coverage .  fever curve monitored closely.
   Response:
   Hemodynamically stable . denies abd pain. Stable abd assessment.
   Plan:
   Continue to follow fever curve and wbc. Administer Antibioitcs as
   ordered.  Continue monitor surgical drsg [**Name5 (PTitle) 43**] [**Name5 (PTitle) **] output. Continue to
   assess pt
s level of pain and medicate with morphine as needed.


MICU NPN 0700-[**2037**]:
  Pt continues to be very hypoxic with POOR activity tollerance.  Many abx added to regimen to cover varicella, atypicals and secondary infection.

  Neuro:  Pt alert and oriented X 3, even during episodes of desaturation to low 80's.  He is able to assist with moving in bed, but he is severely limited by dypsnea.
  CV:  Pt spiked to 101.7 this afternoon--blood cultures sent (urine and sputum sent earlier).  Tylenol administered and changed to ATC.  Pt in ST, rate 110-140's.  Fluids started to treat tachycardia for ? dry fluid balance. Phosphate repleted with 15 mmol Kphos over 6 hours.
  ID:  Vanco and CTX added, acyclovir increased to 1000 mg TID.  Mult viral swabs, skin scrapings, CD-4 count pending.
  Pulm:  Pt continues on 100% NRB plus 6 L NP.  He tollerated about 2 hour period of NRB alone, but then desaturated to low 80's.  He desaturates to low 80's with any activity and is slow to recover.  Lungs CTA.  Cough productive for large amts loose brown sputum.
  GI:  Pt taking small amts of liquids, able to swallow pills.  Throat is very sore.  PO's kept to a minimum in event of extubation (pt still boarderline).  Abd benign.  No stool.
  GU:  Foley draining mod amts amber urine.
  Skin:  Trunk covered with small vescicular lesions--pt reports they are not painful or itchy.  Derm consult believes they are consistant with disseminated zoster.
  Family:  MOther and father in to visit this afternoon.  Both updated on POC.


PE:
Gen: well appearing
Heent: NCAT, AFOF
Chest: CTA
Heart: RRR, no m
Abd: soft, nt, nd
Ext: well perfused


Nursing Progress Note

S: "My breathing feels fine."

O: Please see flow sheet for objective data. Tele sinus rate in 90's. Remains on Lopressor 50mg [**Hospital1 **]. SBP>95 for most of the day. Given Zaroxolyn 5mg and Lasix 120mg IV. Denies chest pain. Restrted on IV Heparin at 1400u/hr post MI. PTT to be checked at 8pm. Seen by CT surgery. OR for CABG sometime next week.

Resp: RR 30-40 and tachypneic although pt denies any shortness of breath at rest. Increasingly winded with minimal activity. OOB to chair for shift. Lungs with rales throughout the bases. Encouraged to take deep breaths. Presently on 6lNC with sats 93-97%. See flow sheet for abgs.

Neuro: Pt is alert and oriented. Poor activity tolerance d/t resp status. Up in cardiac chair for the shift. Repositioned several times.

GU/GI: Appetite is poor. Requesting lots of fluids. Explained to pt the importance of restricting fluid intake. Creat this am 1.6. Fair diuresis from lasix IVP. To be started on lasix drip this pm.

ID: Afebrile today. WBC down to  13,600.  Bld cultures still pending. Conts on Zosyn and Vanco. Level pending from today.

A&P: Pt conts with tenuous resp status.  Slightly improved today with less O2 requirement although pt becomes easily SOB with activity. Check PTT at 8pm. Lasix drip at 15mg/hr for goal of 1-2liter negative today. Pt consult in am if resp status improves.


ECG interpreted by ordering physician.
[**Name10 (NameIs) 2**] see corresponding office note for interpretation.


Chief Complaint: Syncope
   I saw and examined the patient, and was physically present with the ICU
   Resident for key portions of the services provided.  I agree with his /
   her note above, including assessment and plan.
   HPI:
   24 Hour Events:
   Patient with persistent tachycardia noted
   Patient with continued valium dosing
   2 liters IVF given at presentation--now patient with recurrent
   tachycardia this morning following initial favorable response of HR
   with fluid support
   History obtained from [**Hospital 19**] Medical records
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Other medications:
   Changes to medical and family


history:


PMH, SH, FH and ROS are unchanged from Admission except where noted
   above and below
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Cardiovascular: Tachycardia
   Heme / Lymph: Anemia
   Signs or concerns for abuse : No
   Pain: No pain / appears comfortable
   Flowsheet Data as of  [**2106-12-5**] 10:55 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 36.7
C (98.1
   Tcurrent: 35.9
C (96.6
   HR: 88 (88 - 142) bpm
   BP: 120/78(87) {108/62(76) - 147/78(90)} mmHg
   RR: 21 (16 - 26) insp/min
   SpO2: 93%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 60 Inch
             Total In:
                                                                  2,022 mL
                                                                     56 mL
   PO:
             TF:
   IVF:
                                                                  2,022 mL
                                                                     56 mL
   Blood products:
   Total out:
                                                                    350 mL
                                                                    550 mL
   Urine:
                                                                    350 mL
                                                                    550 mL
   NG:
   Stool:


NURSING DISCHARGE NOTE

Baby Girl [**Known lastname 2282**] d/c to home accompanied by [**Known lastname 32**] and 3 y.o. brother. D/c paperwork given to mom including info on Infant f/u, Early Intervention,[**Known lastname 683**], recipe for BM 24, hearing screen and vaccine book.  Mom to call Dr. [**Last Name (STitle) **] in the am for pedi appt.  Mom placed [**Known lastname **] in the car seat and told to call with any ?.


SOCIAL WORK
Mother known to social work from her two admissions to 6s during her high risk pregnancy. Met with mother this am follwoing her delivery. States she is "scared", wishing that NICU providers would be able to tell her news that is more hopeful. Would like to talk with providers later today when her dad is present. Will work to arrange meeting and continue to follow. Thank-you.


MCA stroke days ago now patient weaning on PSV 5/5-.40 with spt VT 300-400,RR20-28. BS clear diminished,low grade fever no recent ABG drawn last one is from 3AM. Full code responding to questions by nodding. Patient suctioned for moderate amount of secretion will continue to closely monitor.


PATIENT/TEST INFORMATION:


Indication:


Abnormal EKG
Height: (in) 66
Weight (lb): 125
BSA (m2): 1.64 m2
BP (mm Hg): 80/50
Status: Outpatient
Date/Time: [**2117-3-29**] at 11:00
Test: TTE(Complete)
Doppler: Complete pulse and color flow
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: The left atrium is mildly dilated.

RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler.

LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left ventricular systolic
function is severely depressed. There is no resting left ventricular outflow
tract obstruction. No masses or thrombi are seen in the left ventricle.

RIGHT VENTRICLE: The right ventricular wall thickness is normal. The right
ventricular cavity is dilated. Right ventricular systolic function appears
depressed.

AORTA: The aortic root is normal in diameter. There are focal calcifications
in the aortic root. The ascending aorta is normal in diameter. There are focal
calcifications in the ascending aorta.

AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not
stenotic. No aortic regurgitation is seen.

MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. The mitral valve supporting structures are normal.
There is no significant mitral stenosis. Moderate to severe (3+) mitral
regurgitation is seen.

TRICUSPID VALVE: The tricuspid valve leaflets are normal. The tricuspid valve
supporting structures are normal. There is no triscupid stenosis. Mild to
moderate [[**12-17**]+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear
structurally normal with physiologic pulmonic regurgitation.

PERICARDIUM: There is no pericardial effusion.

Conclusions:
The left atrium is mildly dilated. The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed (ejection
fraction [**10-4**] percent) secondary to severe hypokinesis/akinesis of all walls
except for the posterior and lateral walls, which are moderately-to-severely
hypokinetic. No masses or thrombi are seen in the left ventricle. The right
ventricular cavity is dilated. Right ventricular systolic function appears
depressed. The aortic valve leaflets (3) are mildly thickened but not
stenotic. No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+)
mitral regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.


Impression:


profound left ventricular contractile dysfunction with
moderate-to-severe mitral regurgitation


still desaturation with po feeding.
PE: agree with [** 18**] [**First Name8 (NamePattern2) 2769**] [**Last Name (NamePattern1) 19**] assessment
wt= 2865 gm -10


[**2164-9-28**] 3:57 PM
 CHEST (PRE-OP PA & LAT)                                         Clip # [**Clip Number (Radiology) 95280**]
 Reason: STROKE;TRANSIENT ISCHEMIC ATTACK
 Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


39 year old man with bacterial endocarditis getting CXR for pre-op prep


REASON FOR THIS EXAMINATION:


pre-op
 ______________________________________________________________________________


FINAL REPORT


REASON FOR


EXAMINATION:


Preoperative evaluation.

 PA and lateral upright chest radiographs were reviewed in comparison to
 [**2164-9-26**].

 Heart size is normal.  Mediastinal position, contour and width are
 unremarkable.  Lungs are clear.  There is no pleural effusion or pneumothorax.


IMPRESSION:


Normal chest radiographs.


Days addendum:

Pt into afib rate 160's. SBP 130's6:15pm.  Lopressor 5mg iv.  Magnesium 2 gm iv.  Converted to SR 6:25pm. Amio had been changed to p.o. this afternoon.  QTC > .50, no bolus given at this time.
Wires and CT's d/c'd this afternoon.  CXR done.
Coumadin started 3mg.


Neonatology
Doign well. Remains in RA. No spells. HAD brady with bottle last night associated with feed. Comfortable apeparing.

Taking feeds well overnight.

[** 8**] doing well with feeds. FU arranged with PMD. VNA arranged. DC summary dicated. PMD [**Last Name (un) **] be contact[**Name (NI) **].

Ready for dc.
 DC prept time 35 minutes.


Lactation Consult
Met w/ mother at 1pm to assess infant latch and review feeding pattern of breastfeeding infant. Infant placed in  cross cradle position using a supportive pillow. Mom's breast and nipple normal appearing and mom able to produce some drops of milk. Infant latched with upper and lower lips flanged and had audible swallows after a sleepy period; mom states that infant usually latches vigorously and has frequent audible swallows. Mom reports hearing swallowing and feeling swallowing on the baby's back. Reviewed voiding and stooling pattern and gave mom the written breastfeeding diary. Also gave mom LC reference for after discharge and encouraged her to utilize lactation services through her pediatrician's office.


nursing update
see flowsheet for specific info

Neuro: pt does not follow commands, opens eyes spontaneously, and tracks to voice.  Moves upper extremities on bed, occassionaly moves lower extremities on bed.  PERRL.  o seizure activity today.

Resp: pt extubated today by RRT,even with marginal mechanics.  Initially patient did okay, with resp rate mid 20s and good sats.  During the afternoon, patient did deteriorate , with increasing resp, rate and especially increasing sputum.  Patient unable to handle secretions, unable to cough on command, and does have a very poor cough effort when he does cough. . Patient currently tachypnic with sats in mid to upper 90's. Dr. [**Last Name (STitle) 1604**] from medicine called to see patient and to assess for himself severity of congestion.  Chest PT done, after which lung sounds were very coarse [**Hospital1 **]-lat.  NT sx'd for moderate amount of thick blood tinged sputum x3 within 1 hr., HO aware, CXR and lasix ordered to Tx. ?Probable reintubation later this evening if does not respond to lasix and aggressive pulmonary toilet.

CV:  NSR, tachy at times, systolic BP in the 150's most of the day.

GU: foley to gravity, UO WNL.  Lasix given twice today with good effect.

GI:  +BS, abd softly distended.  G/J tube to gravity, draining green bilious liqid fluid.  Pt brought to angio for advancement of G/J tube back into the duodenum, brought back to SICU before procedure done because of tachypnea and desaturation. Plan to do proedure early next week.

Social:  [**Name (NI) 25**] mom called and updated as to pt's condition.  Mom states she wishes her son to be reintubated.  She would like to be called if any major changes happen with her son.  She can be reached at ([**Telephone/Fax (1) 8462**]. Mom okay with reintubation.

Plan:  Monitor and replete lytes as needed--aggressive K repletion
       Monitor for seziure activity
       Possible reintubation
       MICU team aware of above, notify HO of any changes.


RESPIRATORY CARE: PT W/ 7.0 ETT @ 23 LIP.
AC 10/700/.50/5 - ABG C/W METABOLIC ACIDOSIS
AND GOOD OXYGENATION. QUESTION OF ETT OBSTRUCTION
BUT R/O BY PAP - PLATEAU P ONLY 4-5 CM H20.

                        [**First Name11 (Name Pattern1) 43**] [**Last Name (NamePattern1) 44**], RRT


[**2187-10-1**] 6:42 AM
 US INTR-OP 60 MINS                                              Clip # [**Clip Number (Radiology) 25301**]
 Reason: exp.lap., right hep lobectomy, cbd excision, roux-en-y hep,
 Admitting Diagnosis: OBSTRUCTIVE JAUNDICE;CHOLANGIOCARCINOMA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


hepatic mass


REASON FOR THIS EXAMINATION:


exp.lap., right hep lobectomy, cbd excision, roux-en-y hep, IOUS
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Hepatic mass consistent with cholangiocarcinoma, intraoperative
 ultrasound requested.


COMPARISON:


Abdominal CTA of [**2187-9-17**] to [**2187-9-28**].

 INTRAOPERATIVE ULTRASOUND:  Son[**Name (NI) 211**] guidance was provided to Dr. [**Last Name (STitle) **]
 intraoperatively during the performance of a laparotomy and evaluation for
 partial hepatectomy for resection of a hilar mass consistent with
 cholangiocarcinoma.  The hepatic echotexture is slightly coarsened and
 heterogeneous, particularly in the left lateral segment, where a focal area of
 relative [**Name (NI) 25302**] most likely corresponds to an area of necrosis in
 segment III, subsequent to a previous hepatic artery embolization.  Evaluation
 of segment II was limited due to presence of a PTC catheter.  The previously
 seen upper abdominal hematoma had been evacuated with small amount of residual
 clot remaining about the periphery of the liver.

 Intraoperative son[**Name (NI) 948**] was somewhat limited by the presence of bilateral
 PTC catheters.  Allowing for this, again demonstrated is an isoechoic mass at
 the porta hepatis that measures approximately 2.1 x 1.1 cm (series 1, image
 1,2).  The right posterior portal vein is mildly focally narrowed at the
 margin of the mass, with associated aliasing(image 3).  The right anterior
 portal vein was again noted to be severely narrowed (essentially occluded) by
 the mass, with distal reconstitution.  There is similar near occlusion of the
 left portal vein also at the margin of the mass just distal to the portal vein
 bifurcation.  The left portal vein remains patent distal to this with slightly
 pulsatile antegrade flow.

 Intrahepatic biliary dilation is decreased since the original CTA with PTC
 catheters in place.  The proximal portion of the left hepatic artery remains
 patent following embolization of more distal branches.

 No lesions suspicious for intrahepatic metastases were identified, although
 sensitivity for detection of metastatic implant is expected to be low given
 the isoechoic nature of the primary mass.


IMPRESSION:


2.1-cm isoechoic hilar mass consistent with cholangiocarcinoma
 with severe narrowing/near occlusion of right anterior and left portal venous
 branches as described.  Intrahepatic biliary dilation improved with PTC
 catheters in place.
                                                             (Over)

 [**2187-10-1**] 6:42 AM
 US INTR-OP 60 MINS                                              Clip # [**Clip Number (Radiology) 25301**]
 Reason: exp.lap., right hep lobectomy, cbd excision, roux-en-y hep,
 Admitting Diagnosis: OBSTRUCTIVE JAUNDICE;CHOLANGIOCARCINOMA
 ______________________________________________________________________________


FINAL REPORT


(Cont)


[**2155-11-20**] 9:54 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 77589**]
 Reason: EVAL FOR STROKE POST LAP /LIMITED RESPONSIVENESS
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


[**Age over 90 **] year old woman s/p ex lap now barely responsive


REASON FOR THIS EXAMINATION:


r/o stroke
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Barely responsive following surgery.


TECHNIQUE:


Axial noncontrast CT scans of the brain were obtained.

 There are no previous studies available for comparison.


FINDINGS:


There are no focal areas of abnormal attenuation within the brain.
 [**Doctor Last Name **] white matter differentiation appears to be preserved.  There is no
 intracranial mass effect. There is no hemorrhage. The ventricles are normal in
 size and configuration.

 Bone window images demonstrate carotid calcifications. There is mild ethmoidal
 thickening.


IMPRESSION:


1) No evidence of acute intracranial hemorrhage or territorial infarction. It
 could be too early to identify infarction by CT scanning. If clinically
 indicated, follow up is recommended.


Respiraotry Care:
Patient received from ED in respiratory distress, secondary to metaboic acidemia (BE = -25). Neb RX X one with little positive outcome. Intubated for respiratory failure with a # 7.5 ett, 23 at the lip.  Pulled out 3 cm to 20 cm, based on radiologic results.  Latest abg revealed an acute, severe metabolic acidemia  with good oxygenation on the current settings.  This is an improvement over the previous results.

No RSBI due to the high concentration of O2 required.


[**2169-9-6**] 11:39 AM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 47476**]
 Reason: r/o PTX
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


[**Age over 90 **] year old woman with chest pain, s/p PICC yesterday.


REASON FOR THIS EXAMINATION:


r/o PTX
 ______________________________________________________________________________


FINAL REPORT


CLINICAL HISTORY:


New PICC placement in patient with chest pain.

 STUDY:  Portable frontal chest x-ray, upright.

 Compared to [**2169-9-2**], a right PICC has been inserted and its tip is in the mid
 SVC.  No pneumothorax.  As before, there is right pleural effusion and right
 base consolidation that could represent aspiration or pneumonia, which appears
 unchanged.  Film is slightly degraded by motion.  Left basilar subsegmental
 atelectasis persists.  Aortic arch calcifications indicating atherosclerosis
 are again noted.


TITLE:
SPEECH AND SWALLOWING FOLLOW UP
Met with pt and her husband at the bedside. She has been ordered
for thin liquids and soft consistency solids, but admits her
intake over the weekend has been poor. Her reduced intake is
multifactorial, reporting fear around eating, lack of appetite
and dislike of the food. She and her husband as well as RN denied
any overt signs of aspiration and she is being encouraged to eat
and drink. Nutrition is following her for a calorie count and is
proving nutritional supplements Benecalorie. Pt has been drinking
some of the supplements, but is refusing the Benecalorie. Her
tube feeding cycle was changed in Saturday and is now Cycled from
8 pm to 6 am to try to increase her appetite / intake during the
day.
I met with the pt at the bedside and had a lengthy conversation.
Pt did not remember having the video swallow Friday and continues
to have fear around eating. She was observed with thin liquids by
straw and soft solids without any overt signs of aspiration. She
continues to have frequent coughing episodes but is managing well
to clear secretions and lower RR with encouragement. Pt was also
encouraged to utilize the electrolarynx, although she reports she
prefers writing and has a white board in the room.
SUMMARY:
Pt continues to tolerate thin liquids and soft, moist solids,
although her intake is limited. I discussed the pt with Nutrition
and we will continue to follow her together to work towards
increasing her PO intake. She can continue on the current PO
diet.
RECOMMENDATIONS:
1. Suggest pt continue on the current PO diet of thin liquids and
soft, moist solids. I do not feel pt needs another video swallow
at this time.
2. Continue to deflate tracheal cuff for PO intake.
3. Meds whole with water as tolerated or via the NG tube.
4. Continue calorie count and supplements as recommended by
nutrition.
5. [**Name (NI) 882**] husband was encouraged to bring in outside food if pt
continues to have limited intake.
6. Encourage use of the electrolarynx.
7. We will f/u later in the week.
__________________________________
[**First Name8 (NamePattern2) 996**] [**Last Name (NamePattern1) 997**], MS, CCC-SLP
Pager#[**Serial Number 3559**]
Face Time: 13:40-14:30
Total Time: 100 minutes
   15:06


Citic/Sicu Nsg Progress Note
0700>>[**2029**]-

EVENTS- weaned nipride drip and decreased labaetalol drip while maintaining bp within goal parameters of 110-150/systolic.
        improved u/o with increased hydration.

Neuro-  PERRL/brisk @ 3-4mm. Pt mae's and inconsistently and occassionally follows commands with all extremities.
**left UE has delayed response in activity; does not appear to be weaker in strength.
**Pt has been somnulent throughout the day; sometimes responding easily to voice and other times requiring persistent verbal and noxious stimulation to obtain a response. Once awake, pt's attention time extremely limited: ~ 10-20 seconds. During these moments, pt would open eyes w/o clear focusing and might respond verbally with 1-3 words spoken clearly. However, pt was unable to respond verbally further to questions/statements other than to to say"uh-[**Doctor Last Name 6245**]" or "let's see". Pt was unable to provide names of family members, but when he initially saw one of his children he might say: "what's up?" and nothing else. He does smile and chuckle appropriately to humorous comments.
At ~ 6pm, pt suddenly became awake: opening eyes and focusing on speaker and visitors, but still unable to respond to questions
or articulate statements. Pt followed commands but slowly..as if he ws not quite sure what to do. Finally ~ 7pm he made his first spontaneous remark: "what kind of drain is it?" question ws made in referrence to a discussion about his ventriculostomy drain and the events that brought him to the hospital.

ICP drain remains @ 5cm above level of tragus and is open to drain. ICP has ranged 5-8 and cont to drain pink tinged fluid at 10-25cc/hr.

No seizure activity noted; no antiseizure meds ordered.

CVS- goal bp >110/ and <150 systolic. Initially required nipride and labeatalol to maintian goal bp parameters. Tolerated weaning of nipride to off and labeatalol to .5mg/min.
...hr 58-60's nsr w/o ectopy
... ekg done; revealing flipped t waves in 1,3,avl and st elevation in v3&4. No prior ekg to compare. Enzymes to r/o mi sent. PND

Resp- nc @ 2l with sats 98-100%. rr in teens w/o distress. breath sounds are clear and equal. abg's wnl

Renal- low u/o this am. received fluid bolus of 500cc and increased hourly rate to 100cc...now u/o is >100cc/hr.
...K+ 3.5; 40meq added to iv fluid.

ID- afebrile; oxaciilin for ventricular drain

Heme- hct 33 x2

GI- npo; soft abd with bowel sounds.

Skin- intact with warm, dry skin and palpable pulses.
      compression boots on.
      remains on BR with HOB elevated 15-30 degrees. Turned s>s q2-3/hr.

A- s/p HTN CVA: right thalmic bleed.
   altered neuro status: somnulent
   HTN- requiring pharmacologic intervention.

P- Cont to monitor hemodynamics and maintain w/in goal range.
   q 1hr neuro assessment
   maintain pt safety and aspiration precautions.
   repeat head CT in am per NS.


0700-1500
neuro: awake, [** 382**], confused, oriented x 0-2, follows commands, moving all exremites, po haldol increased to TID, pt aggitated, 1:1 sitter

cv: hr nsr-st, no ectopy, sbp stable(123-134), po lopressor

resp: doing well on 4 l NP, bs+ all lobes, clear, decreased to bases, R chest pigtail cath to h2o seal today, no drainage, cxr done, no resp distress noted

gi: taking po fair, poor appetite, no n/v, incont stool x 1

gu: foley patent, clear yellow urine, good uo

other: family in & updated on pt's condition, no c/o pain

plan: to dc pigtail tomorrow, if no pneumo & stable tx to floor


Supraventricular tachycardia, rate 150.  Non-specific ST-T wave changes.
This couold be an A-V nodal re-entrant tachycardia or atrial tachycardia.
TRACING #3


NPN 1900-0700
I have examined this infant and agree with above note as written by PCA, [**Doctor First Name 2055**] [**Doctor Last Name 929**].


[**2134-12-15**] 1:05 PM
 BILAT LOWER EXT VEINS                                           Clip # [**Clip Number (Radiology) 30964**]
 Reason: please eval for persistent dvt
 Admitting Diagnosis: CHRON'S FLARE-ABDOMINAL ABSCESS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


51 year old man with h/o dvt


REASON FOR THIS EXAMINATION:


please eval for persistent dvt
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


History of DVT.  Evaluate for persistent DVT.


COMPARISON:


[**2134-9-17**].


TECHNIQUE:


Bilateral lower extremity venous ultrasound.

 LOWER EXTREMITY VENOUS ULTRASOUND (BILATERAL):  [**Doctor Last Name **] scale, color, and Doppler
 images of the right and left common femoral, superficial femoral, and
 popliteal veins were obtained.  Normal flow, compressibility, augmentation,
 and waveforms are demonstrated.  No intraluminal thrombus is identified.


IMPRESSION:


No deep venous thrombosis in right or left common femoral,
 superficial femoral, or popliteal veins.


MICU/SICU NPN HD #30
Events: weaned from neosynepherine gtt

S/O:

Neuro: pt is unresponsive to noxious stimuli, however, pt will suck water from sponges during mouth care, and fingers/toes move reflexivley when palpated, pt will not aknowlege that he is being addressed, nor will he open his eyes, pt will reach for ETT if left hand is not restrained, PERRL 5mm slugish

Pulm: remains intubated on PSV 15+5/0.4, SRR 27-27, LS coarse, suctioned q3-4h for moderate amts thick clear to tan secretions with streaks of blood

CV: HR 88-106 AF, BP 94-121/49-66 off Neo gtt, please see flowsheet for data

Integ: Duoderm over coccyx, multiple eccymotyic areas including right thigh, bilateral lower legs, and numerous needle sticks over abdomen. lower lip is open and bleeding

GI/GU: abd is obese and soft, hypoactive BS, NGT in right nare clamped, NPO, last HD yesterday [**2-3**] next scheduled [**2-5**], pt is anuric

Lines: left radial art line day #2, left IJ QLCL, day #2, right SC Quentin cath, left brachial DL PICC

ID: afebrile on Flagyl & cefepime

Social: this RN spoke at length with pt's wife and HCP, [**Name (NI) **], she was updated on pt's condition and had a fair understanding of pt's long-term need for PEG/trach if his neurological status improves/moderates

A:

high risk for infection r/t invasive lines, ETT, indwelling catheter
altered breathing r/t increased resp secretions, aspiration PNA
high risk for aspiration
impaired skin integrity r/t prolonged immobility

P:

contniue to monitor hemodynamic/respiratory status, continue to wean resp support as tolerated, consult interventional pulmonary re: Per-Q tracheostomy/PEG, frequent repositioning, contniue nutritional support as reccomended


50 yof admitted to [**Hospital1 54**] for elective surgical evaluation of
   mennorrhagia.  s/p exploratory laproscopic attempt anticipation of
   hysterectomy [**2111-8-11**] --> noted uterine fibroids but also significant
   endometriosis --> converted to open procedure.  Significant bleeding
   intraoperatively, required 6 L crystalloid and 4 U PRBC.  Extubated
   post-op, transferred to floor.  Experienced hypotension and
   tachycardia, reduced urine output, Hct= 35 to 25 --> concern for
   persistent bleeding, with falling Hct, required additional 2 U PRBC.
   yesterday, intubated electively, and transferred to IR for planned
   arteriography and possible embolization.  Swan Ganz catheter placed in
   anticipation of large fluid shifts.  Upon receiving 10cc iv contrast
   dye, experienced anaphylaxis (severe bronchospasm, hypotension) -->
   intially difficult to ventilate, but eventually responded to
   treatment.  Back to OR for exploration --> no significant bleeding
   noted (approx. 100 cc) and no intervention required.  Remains
   intubated.  Transferred to ICU service for post-operative care.
   Days events: Pt was extubated this am with out any problems was placed
   on bipap for short period of time this am, that is what she she uses at
   home.  She is now on 2l vis n/c cannula. During the day crit is very
   stable.  Last crit was 30.8.  During the day pt. continued to complain
   about abd. Pain stated it was not incisional but felt like it was
   gas.   She vomited approx. 100cc of green bile, icu team placed ngt
   tube and it immed. Drain 500cc of green bile.
   Acute Pain
   Assessment:
   Pt. contiues to c/o of abd. Pain and incisional pain
   Action:
   Was receiving morphine and fentanyl prn, morphine d/c
d and dilaudid
   added
   Response:
   After pain med pt. states that pain is [**5-5**] after pain med
   Plan:
   Continue to assess pt. for pain and give pain med as needed.
   ------ Protected Section ------
   Crit . has been stable last crit was 30.3
   ------ Protected Section Addendum Entered By:[**Name (NI) 255**] [**Last Name (NamePattern1) 4298**], RN
   on:[**2111-8-14**] 17:47 ------


[**Last Name (LF) **],[**First Name3 (LF) **] J.                    NSURG SICU-A               [**2135-9-9**]  3:26 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 71287**]
 Reason: evidence of bleed?, herniation?
 Admitting Diagnosis: HEAD MASS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


37 year old woman with intracranial mass


REASON FOR THIS EXAMINATION:


evidence of bleed?, herniation?
 No contraindications for IV contrast
 ______________________________________________________________________________
                                  PFI REPORT
 PFI:  Accounting for differences in slice selection and angulation, the size
 of the hemorrhage is not significantly changed when compared to the prior
 exam.  There is increased mass effect of the overlying fourth ventricle as
 well as slight interval increase in size of the lateral and third ventricles.
 There is stable tonsillar herniation.


Neonatology
DOL 10, CGA 34 5/7 weeks.

CVR: Continues in RA, RR 30-50s, comfortable.  No spells, minimal retractions.  Hemodynamically stable, HR 140-150s, BP 75/54 (63).  Completed indocin course with last dose 5 am today.  No murmur heard this morning.

FEN: Wt 1615, up 85 gm.  TF 120 cc/kg/day, D10PN.  Dstik 70. New IV placed last night.  Lytes 130/5.5/97/18/8/0.9.  Voiding 1.4 cc/kg/hr for 24 hours, 0.8 cc/kg/hr overnight, passed small stool.

HEME: CBC this am: 13.3>33.1<498, 49N/2B.

DEV: Isolette.

IMP: Former 33+ wk infant with PDA, overall remains stable.  Comfortable in RA.  Clinically, PDA does not appear evident, although was large on ECHO prior to indocin treatment.

Mild fluid retention, likely secondary to indocin.

PLANS:
- Continue monitoring resp status.
- Continue monitoring for spells.
- ECHO today to assess duct.
- Continue NPO for now, fluid restriction at 120.
- Continue PN.
- Monitor urine output.
- Lytes tomorrow.


NPN DAYS


3. Wt 2280, up 25gms. TF remains at 150cc/kg SC24. Feedings
gavaged over 60min. Bottled x1-took 6cc. Abd benign. No
spits. Voiding and stooling(heme -). Tol feeds.

4. Placed in open crib. Temp remains stable. Active and
alert with cares. AGA.

5. Father called and start of shift. Updated. Loving family.

7. Left eye with clear drainage, cleansed with sterile H2O.
Montior.


Nursing Note (0700-1900hrs)

Mr [**Known lastname **] had an uneventful day; he continues to be febrile however less intense and overall appears to be improving.

Review of systems;
Neuro: Pupils 2mm,sluggish am; versed decreased to 3mg/hr and fent mx'd 50 mcg/hr. Opens eyes to commands however does not follow other commands; no spont mvm't. Responding to questions with eye mvm't. Pupils presently 2mm, brisk. Mod amt discomfort noted with packing of perirectal abscess.

CV: hemodynamically stable with HR 70-80's, NSR despite RVH. CVP 10-12 in afternoon, bolused with 500cc with min effect. Goal is to have CVP >15 for preload dependency. Will prob rebolus. Repleted with 40 KCL. Continues on heparin gtt at 2650units/hr; repeat PTT due 1900hrs; bolused with 10,0000 units heparin 1330hrs to near therapeutic levels. Plastics in to eval perirectal abscess, site clear; source of infect unlikely. Left dorsal of foot with ecchymotic area, site has shifted however not increased.
Resp: LS coarse upper lobes; diminshed/clear lower lobes. Percussion by bed Q1hr. No secretions via ETT. ETT advanced 2cm per team's recommendation, presently at 27cm. Bil PE's with Right [**Doctor Last Name 419**] DVT.
Mx'd on PCV 50%/30/15. Sats >95%. Sitting upright to promote breathing.

GI/GU: Switched to probalance with promod mid afternoon with subsequent drop of BS requiring insulin gtt to be decreased. Hourly BS checks. Presently at 14u/hr of insulin. Abd distended, obese; hypoactive BS however mod amt semi-loose stool via intact rectal bag. Stool for c-diff sent. Adequate u/o, cloudy urine, cx pnd.

ID: NGTD from pan cx; will continue on zosyn/vanco overnoc and d/c am for 72hr coverage. WBC improving. Rash to back resolving. Tylenol x2 for elevated temp. Mx'd 101 most of shift.

Social: Brief call by mother; will visit tomorrow afternoon. Full code.

Plan: Cont present vent settings overnoc. Labs/ABG am. Antibx overnoc. Cont to monitor neuro status; wound care QID to coccyx. Goal u/o >50cc/hr and CVP >15 in light of RHF. Probably repeat echo early this week. Hourly BS checks. Hep gtt goal 60-100. Emotional support.


[**2150-1-12**] 9:47 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 8676**]
 Reason: eval for pneumothorax
 Admitting Diagnosis: PLEURAL EFFUSION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


67 year old woman with R pleural effusion s/p pigtail catheter placement


REASON FOR THIS EXAMINATION:


eval for pneumothorax
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Pigtail catheter placement for pleural effusion, to assess for
 pneumothorax.


FINDINGS:


In comparison with study of [**1-11**], there has been placement of a
 pigtail catheter at the base of the right hemithorax with removal of a small
 amount of pleural fluid.  Substantial residual persists.  Specifically, no
 evidence of pneumothorax.


[**Location (un) 369**]/NEON DOL 27 CGA 37 [**6-15**]
RA, 2 episodes of brady to 57,60, 1 with breastfeeding other with bottle.
Wt 2680 up 85, will go to MM20 cals
To have lactation nurse observe re infant having brady's during breastfeeding.Back on fast flow nipple these past few days and may be reason for brady this am.
Not yet ready for discharge. Mom asked re monitor for home during feeding so she would know when to pull nipple from baby's  mouth.
I told her that I would consider it at a later date and when mom felt confident about dealing with the episodes when they occur.
We can see where we are next week if she continues doing this.
Otherwise baby is doing well.Just immaturity in suck/swallow/breath coordination.


npn 7p-7a


(see nursing flowsheet)

#1  Infant remains on NP CPAP 5cm with fiO2 21% to maintain
Sat >95%.  LS cl and = with  baseline retractions noted,
needing ax q4h for large thick from NP and mouth. Continues
on Caffeine and has had 1 [**Last Name (un) 3180**] so far this shift.  Cont to
monitor resp status and wean to NC after 7days of CPAP.
#2  TF currently at 150cc/kilo... full enteral feed volume.
Feeding PE/BM 20 gavaged over 40min and tolerated well so
far with small if any spits noted and no aspirates.  Abd
soft and nondistended with +BS and is voiding and stooling.
Cont to monitor feeding tolerance now at full feeds.
#4  Infant is alert and active with cares, maintaining temp
in servo isolette on sheepskin with gel pillow.  Sucking on
pacifier and very appropriate.  Support dev needs.
#5  No contact from [**Name2 (NI) 32**] this shift so far, will support.
#7  Repeat bili to be drawn this am and will monitor.


Chief Complaint:
   24 Hour Events:
 TRANSTHORACIC ECHO - At [**2114-1-2**] 09:30 AM
 EKG - At [**2114-1-2**] 10:00 AM
 PICC LINE - START [**2114-1-2**] 10:00 PM
   --Patient persistently tachycardic throughout the day; improved with
   fluids (~1.5 Liters total given) and sedation with fent. and versed.
   However, patient continues to be tachy and we're not sure why.  Is this
   volume depletion or fluid overload?
   --Letter board brought in by patient's family
   --PICC placed
   --Urine output not great.
   --Back on asist control ventilation
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Metronidazole - [**2114-1-2**] 08:13 PM
   Levofloxacin - [**2114-1-2**] 08:36 PM
   Vancomycin - [**2114-1-2**] 09:06 PM
   Cefipime - [**2114-1-3**] 12:00 AM
   Infusions:
   Fentanyl - 50 mcg/hour
   Midazolam (Versed) - 1 mg/hour
   Other ICU medications:
   Heparin Sodium - [**2114-1-2**] 04:31 PM
   Fentanyl - [**2114-1-2**] 08:08 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  [**2114-1-3**] 07:53 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.3
C (100.9
F) at 4pm yest
   Tcurrent: 37.3
C (99.1
   HR: 107 (92 - 125) bpm
   BP: 98/55(69) {98/55(69) - 156/92(112)} mmHg
   RR: 16 (16 - 32) insp/min
   SpO2: 99%
   Heart rhythm: ST (Sinus Tachycardia)
   Wgt (current): 92 kg (admission): 87.5 kg
             Total In:
                                                                  3,079 mL
                                                                  1,322 mL
   PO:
             TF:
                                                                    100 mL
                                                                    147 mL
   IVF:
                                                                  2,909 mL
                                                                  1,175 mL
   Blood products:
   Total out:
                                                                    615 mL
                                                                    150 mL
   Urine:
                                                                    615 mL
                                                                    150 mL
   NG:
   Stool:


Admission Note
Neonatal Attending


History:


Boy [**Known lastname 2926**] was delivered by c/s at 35.4 wk GA to 29 yr old G1 P0 due to maternal progressive HELLP syndrome. Maternal PNL: O+, Ab neg, RPR nr, HepBsAg neg, Rub Im, RPR nr, GBS unk. ROM at time of c/s. Infant's Apgars were 8 and 9 at 1 and 5 min.

Mat Past med hx: not contributory to infant's condition.
Fam Hx: non contributory to infant's condition.
Social Hx: not contributory to infant's condition.

Previous attending notes relate to examination and admission status and plan for infant.


Nursing Progress Note:
Please refer to CareVue for details.
   Pt alert and oriented x3. Pleasant and cooperative w/ care. Clear speech. Follows commands and moves all extremities. No seizures noted. Pt on phenytoin 100mg PO BID. Pt denies having any chest pain. Tmax 99.1. HR 70-80s (NSR w/ rare PVCs). NBP 90s-130s/30s-60s. +1 edema on BLE; DP/PT pulses weakly palpable. Venodyne boots on. Hct q8hr. Last Hct was 31; next Hct due at [**2130**]. Troponin 0.5 (MICU team aware); per MICU team, check troponin qdaily w/ AM labs. Left femoral dialysis line to be pulled out by MICU team today prior to transferring pt to floor. Pt on bedrest while dialysis line still in place. Right AV fistula w/ +thrill/+bruit. Hemodialysis tomorrow. Lungs clear; diminished at times. Pt desats to 91-92% on room air; O2 sat >/= 96% on 2L nasal cannula. Pt w/ strong, nonproductive cough. RR 13-18. Abdomen softly distended w/ +BS. Pt tolerating renal diet well; needs assistance ordering meals. No c/o nausea. No BM today; pt on stool softeners. Pt using urinal appropriately. 20cc clear, yellow urine at 1500. Right lower arm w/ skin tear measuring 4cm long and 0.5cm wide; no drainage noted (left open to air). Left upper arm w/ small skin tear; small amount bloody drainage (DSD intact). [**Name (NI) 98**] wife called x2; will visit this afternoon.
   Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. MICU team to pull out left femoral dialysis line prior to transfer to floor; monitor for bleeding once line removed. Hemodialysis tomorrow. Monitor for chest pain. Check Hct q8hr; goal >30. Update pt and wife on plan of care. Continue ICU care and treatment. Transfer to medical floor when telemetry bed becomes available.


[**2195-8-3**] 11:35 AM
 T-TUBE CHOLANGIO (POST-OP)                                      Clip # [**Clip Number (Radiology) 33362**]
 Reason: assess for stricture, dilation
 Admitting Diagnosis: LIVER FAILURE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


53 year old man with OLT [**7-28**]


REASON FOR THIS EXAMINATION:


assess for stricture, dilation
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


53-year-old male status post orthotopic liver transplant.  Assess
 for stricture or bile dilatation.

 COMPARISONS:  No comparisons are available.

 T-TUBE CHOLANGIOGRAM:  A scout view was obtained and demonstrates a T-tube as
 well as surgical drains and multiple clips and skin staples.  Approximately 15
 cc of nonionic IV contrast were administered under gravity.  The opacified
 bile duct, right hepatic duct, and left hepatic duct as well as a few right
 biliary radicals. There is a hepatic-jejuno anastomosis.

 There is no evidence of bile leak, stricture or biliary duct dilatation. There
 is prompt emptying within duodenum.  The tip of the catheter is located in the
 right hepatic duct.


IMPRESSION:


No evidence of leak, stricture or biliary duct dilatation.


[**2190-11-5**] 1:17 AM
 CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN               [**Name Initial (PRE) 26**] # [**Clip Number (Radiology) 113695**]
 Reason: s/p R TLC insertion-check placement
 Admitting Diagnosis: PERICARDIAL EFFUSION;DYSPNEA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


87 year old woman with R pleur-x catheter s/p pericardial window


REASON FOR THIS EXAMINATION:


s/p R TLC insertion-check placement
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Status post pericardial window and pleural catheter placement.
 New central line placement.

 COMPARISONS:  [**2190-11-4**].

 SINGLE VIEW CHEST, AP UPRIGHT: There has been interval placement of a right
 subclavian CVL with the tip in the mid SVC.  Right-sided pleural catheters are
 in unchanged position.  There is improved aeration of the right lower lobe
 with persistent small bilateral pleural effusions.  There is no pneumothorax.


[**2105-5-21**] 10:05 AM
 DUPLEX DOPP ABD/PEL; US ABD LIMIT, SINGLE ORGAN                 Clip # [**Clip Number (Radiology) 4465**]
 Reason: TX LIVER
 Admitting Diagnosis: GASTROINTESTINAL BLEED-ADVANCED LIVER FAILURE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


47 year old man with etoh cirrhosis, melena s/p liver transplant [**5-20**].
  please evaluate HA/PV/IVC/CBD.


REASON FOR THIS EXAMINATION:


evaluate liver graft.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Post op day 1 from liver transplant.  Please evaluate hepatic
 vasculature.

 TRANSPLANT LIVER ULTRASOUND:  The liver has a uniform echotexture.  There is
 no ascites around the liver.  There is no perihepatic hematoma.

 The Doppler examination demonstrates normal flow on color and Doppler imaging
 in the hepatic veins, portal vein including the right and left branches, and
 the hepatic arteries including the right and left branches.  The resistive
 indices range from 0.62 to 0.69.  There is normal flow within the IVC.


IMPRESSION:


Normal transplant liver Doppler.


Transplant, kidney (Renal transplant)
   Assessment:
   Patient had kidney transplant [**2144-8-15**]
   1 x jp drain, moderate drainage noted


Respiratory Care
Pt trached on trach collar all shift. Has periods of agitation with increased RR and noisy respirations but not wheezey. BS do not change with sx nor MDI administration. Vital signs and oxygenation stable. Appears to tol trach collar, but mental status makes it difficult to assess comfort level.
continue trach collar as tol.


[**2154-8-7**] 12:14 PM
 CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE            Clip # [**Clip Number (Radiology) 17555**]
 Reason: eval for decreased ptx back on sxn
 Admitting Diagnosis: RULE OUT TUBERCULOSIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41 year old woman with chronic lung disease s/p VATS-ptx on water
  seal-back to sxn


REASON FOR THIS EXAMINATION:


eval for decreased ptx back on sxn
 ______________________________________________________________________________


FINAL REPORT


AP CHEST


HISTORY:


Pneumothorax.  Chest tube to water-seal.


IMPRESSION:


AP chest compared to chest films since [**8-1**], most recently
 11:00 a.m. today:

 A moderate-to-large right pneumothorax is smaller and the upper portion of the
 mediastinum has returned to the midline.  Small volume of right pleural
 effusion is layering posteriorly.  There has been no change in the appearance
 of the right lung biopsy site to suggest hemorrhage.  Multifocal infiltrative
 opacities in the left lung are unchanged.  Heart size is normal.


Hypotension (not Shock)
   Assessment:
   Levophed gtt infusing at start of shift
   SBP 120s-150s
   ^ with nursing care and stimulation SBP 180s
          HR ^ 130s with nursing care and agitation as well
   Action:
   Levophed titrated to keep SBP 120-180
   Pt required ^ dose of propofol d/t  hemodynamic instability
          SBP ^ 180s and HR ^ 130s
   Ativan 1mg given IV during periods of ^ hyperdynamics
   Response:
   SBP 120s-150s most of shift with pt adequately sedated
   Plan:
   Keep SBP 120-180 per NMED team
   Keep adequately sedated to avoid fluctuation in hemodynamics
   ? possibility of trying precedex for sedation
   Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)
   Assessment:
   Rectal and oral temps inconsistent
          Oral ^ 103.9 and rectal 102.9
 following rectal temp
          Shivering, clamping down and occasional ?able posturing
   (NMED r/o seiziures)
          HR ^130s
   Zosyn started per NMED
   WBC 11.3
   Thick yellow [** 1056**] tinged seretions from ETT
   Copious amounts of thick yellowish/green secretions suctioned from
   nares and back of throat
          ? sinus infection
   Urine clear yellow with brown sediment noted
   Action:
   Tylenol PO given
   Cooling blanket placed on pt
   [**Name (NI) **] cultures x 1 sent
   Urine culture and analysis sent
   Sputum sent from nasopharyngeal
   Acyclovir per orders
   1 time dose of 4.5g Zosyn given IV
   Dilantin 100mg IV
   Response:
   Waiting for ID approval of zosyn 2.5g Q6
   Plan:
   Monitor temp per rectal probe
   Tylenol and cooling blanket prn
   Cultures pending
   ***Heparin gtt ^ 1000 units @ 0130 for PTT 39.8
          Recheck PTT @ 0730
          GOAL 60-80
   ***PEEP ^ 8
          Pt sat dropped to 93% and stayed
          L side extremely coarse sounding
          Suctioned and recruitment breath given x 2 without sustained
   ^ sat
          ABG showed PO2 77
   o         ^ PEEP 8
   o         ABG wnl


Chief Complaint:  dyspnea and hypoxia to 85% on RA
   HPI:
   Ms. [**Known lastname 8394**] is an 81 year old Russian speaking female with a history of
   anemia, Crohn's disease on chronic steroids, PE, on home O2, discharge
   yesterday after an admission including ICU stay for pneumonia.
   .
   Her friend who saw the patient on the day of discharge recalled that
   she appeared depressed upon arrival to rehab. She was more somnolent
   and lethargic. Prior to discharge she was in good spirits with good
   appetite. Then the next morning (the day of presentation) the patient
   started coughing while being turned in bed. She then complained of SOB.
   Her O2 Sat was found to be 85% on RA. Of note, pt denied any pain,
   including chest pain/pressure.
   .
   Upon arrival to the ED, her vitals wer T 98, BP 132/53, HR 92, RR 24,
   95% on NRB.  She was noted to be somnolent and so an ABG was performed
   which showed hypercarbia.   She was placed on BIPAP and her mental
   status returned to baseline. She was transiently hypotensive to 85
   systolic, so got a 500 cc NS bolus. She got a CXR which showed a new
   LUL infiltrate and so was given Vnacomycin, Zosyn, and Levofloxacin in
   the ED.
   Impaired Physical Mobility
   Assessment:
   Action:
   Response:
   Plan:
   Impaired Skin Integrity
   Assessment:
   Action:
   Response:
   Plan:
   Cellulitis
   Assessment:
   Action:
   Response:
   Plan:
   Alteration in Nutrition
   Assessment:
   Action:
   Response:
   Plan:
   Respiratory failure, acute (not ARDS/[**Doctor Last Name **])
   Assessment:
   Action:
   Response:
   Plan:
   ------ Protected Section------
   ------ Protected Section Error Entered By:[**Name (NI) **] [**Last Name (NamePattern1) 4416**], RN  on:[**2194-4-10**]
   06:21 ------


[**2132-7-1**] 5:06 PM
 RENAL U.S. PORT                                                 Clip # [**Clip Number (Radiology) 76212**]
 Reason: R/O HYDRO/PT IN MICU ABD FLUID/RETENTION
 Admitting Diagnosis: ESOPHAGEAL MASS\EUS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


53 year old woman with liver failure, ?hepatorenal syndrome.


REASON FOR THIS EXAMINATION:


r/o hydro
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw TUE [**2132-7-1**] 7:56 PM
  No hydronephrosis.  Pleural effusion.  Abdominal ascites.  Foley and
  decompressed bladder.
 ______________________________________________________________________________


FINAL REPORT


RENAL ULTRASOUND


HISTORY:


53-year-old woman with liver failure, question of hepatorenal
 syndrome.  Evaluate for hydronephrosis.


COMPARISON:


Ultrasound-guided paracentesis, [**2132-6-27**].


FINDINGS:


There is a right-sided pleural effusion and intra-abdominal fluid.
 No hydronephrosis.  The right kidney measures 11 cm and the left kidney
 measures 9.5 cm.  Renal parenchyma appears unremarkable without masses or
 renal calculi. There is a Foley in a decompressed bladder.


IMPRESSION:


1.  No hydronephrosis.

 2.  Right pleural effusion and intra-abdominal ascites.
                                                                       DFDdp


Admission Date:  [**2184-2-12**]       Discharge Date:  [**2184-2-16**]

Date of Birth:   [**2127-6-20**]       Sex:  F

Service:  CT Surgery

HISTORY OF PRESENT ILLNESS:  The patient is a 56 year old
female who had the onset of palpitations approximately one
year ago.  The palpitations episode lasted approximately ten
to 15 minutes.  She occasional experienced left-sided chest
discomfort with the palpitations, and experienced shortness
of breath and fatigue.

A recent echocardiogram revealed a large atrial septal
defect.  The echocardiogram was performed on [**2183-11-11**]
and showed enlargement of both atria, normal left ventricular
function, dilated right ventricle, large atrial septal
defect, moderate tricuspid regurgitation, moderate pulmonary
hypertension, and dilated pulmonary artery.

PAST MEDICAL


HISTORY:


1.  Hypertension.  2.  Status post
appendectomy.  3.  Hiatal hernia.

MEDICATIONS ON ADMISSION:  Atenolol 25 mg p.o.q.d.

ALLERGIES:  The patient has no known drug allergies.

PHYSICAL


EXAMINATION:


On physical examination, the patient
had a heart rate of 60, blood pressure 148/90 and respiratory
rate 18.  General:  Patient was in no acute distress.  Chest:
Clear to auscultation bilaterally.  Cardiovascular:  Regular
rate and rhythm, normal S1, split S2, systolic murmur heard
loudest over right sternal border.  Abdomen:  Soft,
nontender, nondistended.  Extremities:  No edema or
varicosities.

HOSPITAL COURSE:  The had minimally invasive closure of her
atrial septal defect with a Dacron patch, performed on
[**2184-2-12**].  The pericardium was left open and two
ventricular and two atrial cardiac wires were placed as well
as one right pleural tube.

Postoperatively, the patient was transferred to the Intensive
Care Unit, where she was rapidly extubated.  A nitroglycerin
drip was started an appropriately weaned and she was placed
on perioperative Kefzol.

On postoperative day number one, due to low output of the
chest tube, it was removed.  The patient was transferred to
the floor on postoperative day number one.  She had an
episode of rapid atrial fibrillation, for which she was rate
controlled with Lopressor and an amiodarone drip was started.

On postoperative day number two, the patient was switched to
oral amiodarone.  She remained in sinus rhythm throughout the
remainder of the admission.  The patient was tolerating a
regular diet well.  She achieved level V activity.  On
postoperative day number three, the patient's cardiac wires
and Foley catheter were removed.

Laboratory data on discharge:  Hematocrit 25.6, sodium 133,
potassium 4.4, chloride 95, bicarbonate 29, BUN 13,
creatinine 0.8 and glucose 126.

CONDITION ON DISCHARGE:  Stable.

MEDICATIONS ON ADMISSION:
Lopressor 12.5 mg p.o.b.i.d.
Amiodarone 400 mg p.o.t.i.d. times five days then 400 mg
p.o.b.i.d. times seven days then 400 mg p.o.q.d. times 14
days.
Potassium chloride 20 mEq p.o.q.d. times seven days.
Lasix 20 mg p.o.q.d. times seven days.
Ecotrin 325 mg p.o.q.d.
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Colace 100 mg p.o.b.i.d.

DISCHARGE STATUS:  The patient was discharged to home.

DISCHARGE FOLLOW-UP:  The patient was instructed to follow up
with Dr. [**Last Name (STitle) 1537**] in four weeks and with her primary care
physician in three weeks.

DISCHARGE DIAGNOSIS:
Status post atrial septal defect repair.





                            [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D.  [**MD Number(1) 1540**]

Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36

D:  [**2184-2-15**]  14:22
T:  [**2184-2-15**]  14:39
JOB#:  [**Job Number 28151**]


Sinus rhythm. First degree A-V delay. Inferior and question posterior
myocardial infarction, age indeterminate. Diffuse non-specific ST-T wave
abnormalities. Since the previous tracing of [**2178-8-30**] P-R interval has prolonged
further, ventricular ectopy is absent and further ST-T wave changes are
present.


[**2131-11-19**] 1:18 PM
 1101 BONE DENSITOMETRY                                          Clip # [**Clip Number (Radiology) 34041**]
 Reason: POST MENAP/CAL DAILY
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Postmenopausal, calcium daily.


TECHNIQUE:


Dual-energy x-ray absorptiometry was performed on a GE Lunar Prodigy machine
 at [**Location (un) 11125**].


FINDINGS:


In the lumbar spine, BMD was measured from L1 through L4 as 1.345 g/cm2.  This
 corresponds to a T-score of 1.4 and a Z-score of 2.1.  Today's BMD measurement
 is compared with the measurement performed on [**2130-9-20**] of 1.298 g/cm2 and
 represents minimal interval increase (3.6%).

 In the proximal femoral neck, BMD was measured as 0.776 g/cm2 on the right and
 0.881 g/cm2 on the left.  The mean BMD corresponds to a T-score of negative
 1.5 and a Z-score of negative 0.6.  Today's BMD measurement is compared with
 a measurement of 0.910 g/cm2 performed on [**2131-9-20**]. This represents a moderate-
 to-large interval decrease in bone mineral density (negative 8.9%).


IMPRESSION:


BMD corresponds to the World Health Organization definition of
 osteopenia based on measurements in the proximal femurs.  Compared with
 [**2130-9-20**], there has been a moderate-to-large interval decrease in bone mineral
 density in the proximal femurs, with possible minimal interval increase in the
 lumbar spine.


Respiratory Care Note
Pt. continues on 5cmH2O of nasal prong CPAP and 21%.  On Caffeine.  To follow.  Plan is to trial off CPAP Thursday.


[**2168-6-7**] 5:51 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 69963**]
 Reason: Pls eval for infiltrate, edema
 Admitting Diagnosis: CONGESTIVE HEART FAILURE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


79 year old man with critical AS, new hypotension


REASON FOR THIS EXAMINATION:


Pls eval for infiltrate, edema
 ______________________________________________________________________________


FINAL REPORT


AP CHEST 6:02 A.M. [**6-7**]


HISTORY:


Critical aortic stenosis, new hypotension.


IMPRESSION:


AP chest compared to [**6-6**]:

 Mild pulmonary edema is new, left lower lobe atelectasis and small to moderate
 bilateral pleural effusions unchanged.  Heart size top normal, stable.  No
 pneumothorax.


Neuro:  PT remains [** **] and oriented to self, Pupils 3mm brisk. MAE, and able to follow directions. Pt denies pain.
CV: afebrile, HR 70-80's NSR with rare PVC. SBP 90-100. extremities warm with +PP, continues with generalized 3+ pitting edema. Unable to obtain am labs due to no access. Able to draw last [** **] at 2200,at 0100 Lab called to inform staff of coags clotted,
RESP: lungs rhonchi through-out, LLL remains dim, occasional suctioning of thick tan sputum, spec sent to lab.
GI: started on impact with fiber 3/4 strength at 80cc/hr. 1 small liquid stool
GU: foley draining adequate amount so of cloudy yellow urine.
PLAN:  monitor respiratory status,


7p to 7a MIcu Progress Note

Overview of Events - pt with increasing confusion and agitation. Pulled out RIJ line causing BP to drop to upper 60's until iv access re-established.

Neuro - As per above, pt more confused, at times only oriented to name. Grunting and moaning freq but usually denies pain or any complaints when questioned. Poor historian.  Restless throughout the night and slept little. Pt reassured and reoriented but bilateral hand restraints applied for safety.

C-V - HR 90 -100 SR, no ectopy noted. Levophed titrated to maintain MAP 55-60 and SBP > 90. Levophed currently infusing at .12mcgs/kg/[** 199**]. EKG taken last eve to compare previous EKG taken during the day shift - no acute changes noted.

Resp - LS clear, diminished with occas crackles at the bases. Pt denies sob.  On RA 02 sats > 95%. RR 18-25.

GI - Abd appears increasingly distended and firm. Results of [** 7778**] still pend. Hypoactive BS. TF held throughout the night. Pt vomited ~30 ccs bilious fluid after drinking sips of h20. Peg attached to WS and drained another 30ccs bilious fluid. Pt treated with 12.5mg iv dolasetron mesylate with ? results - no further vomiting. Medicated only once with 2 mg iv morphine at 2200 for mild abd discomfort. Denied any abd pain with this episode. Flexiseal drained 600ccs golden brown liquid guiac net stool. Hct rising to 32.3.

F/E - Anuric. Am lytes pend.

ID - Afeb. WBC continues to rise, now 27.5. 2 sets of Bld Cxs sent. Antibiotics chaned to pipercillin q 8hrs.

Skin - Coccyx less reddened in appearance.  Turned freq and barrier cream and miconazole power applied. Pt appears increasingly more jaundiced appearing. Denies pruritus.

Access - RIJ replaced with R Fem tri-lumen line. No bleeding noted from former RIJ site. Unable to insert peripheral iv after numerous attempts by several staff members. Fem line bleeding - surgicel applied with resolution.

[**Name (NI) 7779**] - Wife called for update on pt's condition.


Admission Date:  [**2187-6-14**]              Discharge Date:   [**2187-7-13**]

Date of Birth:  [**2136-7-5**]             Sex:   M

Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
gastroporesis with PEG/J placement

Major Surgical or Invasive


Procedure:


EGD
PEG/J

History of Present Illness:
50 yo man with complicated PMH significant for DM1 s/p renal
transplant, multiple CVA (last [**5-/2186**]), PVD, hypothyroid who
presents as a direct admit for EGD and possible PEG in AM in
response to gastroporesis. Pt being followed by Gi in regards to
a few month history of increasing nausea and emesis, becoming
almost refractory in the last 4 weeks. Workup included gastric
emptying study which showed only 2% of food passed from
esophagus to stomach. Currently Pt without complaint: no N/V/D,
no CP/SOB, no HA/LH.

Past Medical


History:


DM1 (s/p renal Tx)
multiple CVAs
PVD
Hypothyroidism
HTn
Depression

Social


History:


Lives at rehab. Married. No tobacco or EtOH.

Family


History:


NC

Physical


Exam:


Temp 97.3
BP 120/70
Pulse 84
Resp 20
O2 sat 97%
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, dry mucous
membranes
Neck - no JVD, no cervical lymphadenopathy, supple, no bruits
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with hypoactive bowel
sounds
Skin - No rash. Skin warm and moist.
Extr - No clubbing, cyanosis, or edema. LE boots and dressings.
Neuro - Alert and oriented x 3, cranial nerves [**1-18**] intact,
upper extremity strength 4/5 and lower extremetity R3/5 and L4/5
but proximal strength intact, sensation grossly intact.
Decreased speech but understands and follows commands
appropriately.


Pertinent Results:
[**2187-6-14**] 07:25PM BLOOD WBC-7.9 RBC-4.64 Hgb-14.5 Hct-41.6 MCV-90
MCH-31.1 MCHC-34.7 RDW-16.0* Plt Ct-359

[**2187-7-11**] 10:30AM BLOOD WBC-14.6* RBC-3.39* Hgb-11.1* Hct-32.1*
MCV-95 MCH-32.9* MCHC-34.7 RDW-15.0 Plt Ct-284
[**2187-6-14**] 07:25PM BLOOD Neuts-80.3* Lymphs-12.1* Monos-6.1
Eos-1.2 Baso-0.3
[**2187-7-9**] 07:21PM BLOOD Neuts-85.0* Lymphs-7.2* Monos-5.9 Eos-1.5
Baso-0.3
[**2187-7-3**] 10:17AM BLOOD PT-12.8 PTT-37.6* INR(PT)-1.1
[**2187-6-14**] 07:25PM BLOOD Glucose-213* UreaN-26* Creat-1.0 Na-139
K-4.6 Cl-102 HCO3-30* AnGap-12
[**2187-7-11**] 10:30AM BLOOD Glucose-269* UreaN-22* Creat-1.1 Na-132*
K-4.4 Cl-95* HCO3-29 AnGap-12
[**2187-6-22**] 10:01AM BLOOD Amylase-18
[**2187-6-22**] 10:01AM BLOOD Lipase-9
[**2187-6-14**] 07:25PM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.0 Mg-2.0
[**2187-7-11**] 10:30AM BLOOD Calcium-8.6 Phos-1.5*# Mg-1.6
[**2187-6-22**] 10:01AM BLOOD Triglyc-45
[**2187-6-14**] 09:45PM BLOOD T4-6.4
[**2187-6-21**] 01:56AM BLOOD freeCa-1.26
[**2187-6-22**] 02:43PM BLOOD freeCa-1.17
[**2187-6-26**] 07:09PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2187-6-26**] 07:09PM URINE RBC-2 WBC-12* Bacteri-MOD Yeast-FEW Epi-0
**


FINAL REPORT


[**2187-7-1**]**
   AEROBIC BOTTLE (Final [**2187-7-1**]):    NO GROWTH.
   ANAEROBIC BOTTLE (Final [**2187-7-1**]):    NO GROWTH.
*
GASTRIC EMPTYING STUDY ([**2187-6-8**])
INTERPRETATION: Following a meal of radiolabeled egg-whites,
anterior and
posterior imaging was performed for two hours.
There is a large amount of residual food within the esophagus.
Over a course of
two hours, the stomach slowly empties. However, there is almost
no progression
of food from the esophagus into the stomach, even after two
hours. After two
hours, less than 2% of the material was passed from the
esophagus.


IMPRESSION:


Little passage of food from the esophagus into the
stomach.
Gastric emptying is also delayed; however, since much of the
meal remained in
the esophagus throughout the study, the volume of the meal in
the stomach is
non-standard.
*
MRI OF THE BRAIN ([**2187-6-18**]):
The exam was compared to the patient's prior CT scan of [**2186-10-2**]
and prior MR study of [**2186-7-28**].
There is no evidence of abnormal diffusion to suggest the
presence of acute
infarction. Abnormal signal foci are present in the central pons
and the
cerebral peduncles consistent with remote ischemic disease.
There are multiple
remote infarcts in the thalami, basal ganglia and
periventricular white
matter. There is no evidence of acute mass effect or hemorrhage.
There is no
displacement of normally mid-line structures. There is no
evidence of a focal
extra-axial lesion or fluid collection. The increased signal in
the peduncles
on the T2 weighted sequences may be new from the previous
examination, though
this is difficult to say with certainty because of motion
artifact on the
prior study. Certainly there are low density areas within the
peduncles on the
prior CT scan of [**2186-10-2**].


IMPRESSION:


No definite evidence of new acute infarct. Probably
stable
appearance compared to prior examination. See above discussion.
MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES:


FINDINGS:


There is no evidence of aneurysm or flow abnormality.
The
examination is unchanged from prior study of [**2186-7-28**].


IMPRESSION:


Negative MRA of the circle of [**Location (un) 431**].
*
ACUTE ABDOMINAL SERIES ([**2187-6-21**])


FINDINGS:


There is a large amount of free air. Percutaneous
gastrostomy tube
is noted in the left upper quadrant. There is gas and stool
throughout the
colon. Retained contrast material is seen within the descending
colon and
rectum. Dense vascular calcifications are present. Degenerative
changes are
seen at the hips.


IMPRESSION:


Large amount of free air. Although 3-5% of patients
may have a
small amount of free air following PEG tube placement, the
volume here is
concerning for a perforation.
*
CT ABD w/o CONTRAST ([**2187-6-21**]):


IMPRESSION:


1) Massive pneumoperitoneum. The cause of this is likely leaking
of air from
the stomach into the peritoneum through the site of the PEG
insertion. There
is no evidence of hemorrhage or free fluid.
2) Two small gallstones are seen.
3) Small hiatal hernia.
4) Extensive vascular calcifications.
*
ABDOMEN, TWO VIEWS ([**2187-6-25**]): Tube overlies the antral region of
stomach. No free
intraperitoneal gas. There is retained contrast in the bladder
from prior CT
scans. Gas and fecal residue are present throughout the colon.


IMPRESSION:


No evidence of free intraperitoneal gas
*
MRI HEAD ([**2187-6-26**]):


FINDINGS:


The diffusion-weigted images are normal. The multiple
areas of
presumed prior infarction described in detail on the prior MR
study report of
[**2187-6-18**], are redemonstrated as is the punctate area of
susceptibility
within the posterior limb of the right internal capsule. The
principal
vascular flow patterns are identified. No overt new extracranial
pathology is
idenified.
CONCLUSION: Stable, markedly abnormal study as defined above.
*
CXR ([**2187-7-11**]):
CHEST AP: The cardiac, mediastinal and hilar contours are stable
in
appearance. Pulmonary vasculature is normal. There are bilateral
lower lobe
opacities greater on the left than the right. The bilateral
nature of these
opacities is concerning for aspiration pneumonitis. There is a
possible small
left pleural effusion. Osseous and soft tissue structures are
unremarkable.
Left subclavian CVL tip remains in the SVC.


IMPRESSION:


Bilateral lower lobe patchy opacities greater on the
left which
are concerning for aspiration pneumonia.




Brief Hospital Course:
By Problem:
1) GASTROPARESIS:  Patient was admitted electively on [**2186-6-13**] for
PEG placement, d/t 1 mo of severe N/V and weight loss.  Delayed
gastric emptying with possible esophageal dysfuntion.
Videoswallow [**2187-5-29**]: Difficulty initiating swallow, no
laryngeal closure, delayed swallow, severe aspiration.
Esophageal emptying study showed <2% over 2 hrs.  EGD [**2187-6-15**]
showed scant amt retained debris in esophagus c poor motility.
Swallow consulted re: current safety for po's.  Recommended that
with both esophageal and oropharyngeal problems, that patient be
NPO but if desired can take very little by mouth, 3 teaspoons of
honey-thick liquid or ground diet, no more than 3 teaspoons in 6
hours.  PEG placement was complicated by pneumoperitoneum and
DKA; s/p ex-lap [**6-23**]. Transferred back to medicine service
[**2187-6-25**] for further management.  Patient had occasional N/V, but
overall tolerated PEG tube feeds well.  If N/V occurred tube
feeds were held, or stopped and the patient's N/V usually
resolved.
*
2) TYPE I DIABETES:  Had been on glargine 32 units qnight and
lispro sliding scale qid. Increased glargine to 36U QHS.  FS's
have been better controlled.  Continued humalog ISS.
*
3) HYPOTENSION: Patient episodes of low BP's to high 80's
systolic.  Medical team decreased metoprolol to 12.5 [**Hospital1 **] and
increased hold parameters to 110 systolic. When episodes of
hypotension, patient given 500 cc bolus of NS and responded well
with appropriate increase in BP.
*
4) CONSTIPATION: In addition to oropharyngeal dysphagia and
esophageal dysmotility, pt has gastroparesis and had extreme
difficulty stooling.  Patient received GoLytley, multiple
disimpactions, and lactulose tid.  He is now stooling, about BM
x 2-3 per day on colace, senna, ducolax regimen.  If patient
gets behind at all, restart lactulose.
*
5) UTI:  Ucx from [**2187-6-21**] showed Pseudomonas and Enterococcus;
U/A from [**6-21**] positive, however, U/A from [**6-25**] negative. U/A
from [**6-26**] is positive --> treated with Zosyn x 2wks. Zosyn day 1
was [**2187-6-29**] (final day will be [**Last Name (LF) 2974**], [**7-13**]).
*
6) LOW GRADE TEMP & LEUKOCYTOSIS: patient had low grade temp
(100.1) and leukocytosis on [**2187-7-11**]; CXR obtained which showed
"bilateral lower lobe patchy opacities greater on the left which
are concerning for aspiration pneumonia."  Patient was started
empirically on Levo/Flagyl on [**2187-7-11**].  He has remained afebrile
since.  Treatment should extend for one week, to be completed
[**2187-7-18**].
*
7) ? DEPRESSION/SOCIAL:  Patient with ?depression (talks less,
less eye contact, even less facial expression, won't respond,
point, nod, etc.)  Early in his admission, he had some thoughts
of going home & stopping tube feeds. Feels depressed (is on
Celexa) but was not interested in psych visit.  Said he would
feel better if he could go to rehab with strong PT program.
Chaplain has come to try to help with some of these issues, with
apparent minimal success.  Patient has a very involved family,
[**Doctor First Name **] (proxy) and two other sisters.  Family members "are not
willing to give up on [**Doctor First Name **] yet" and are no where near approaching
palliative care or hospice. They would like him to go to an
acute rehab but he has been rejected from approx 30 places.
There is also an insurance issue, as well as a divorce issue
(patient's wife is divorcing him, and patient is also depressed
that his children are being told to hate him by their mother).
*
8) H/O CVAs: On plavix and aspirin for anticoagulation.  Neuro
consult early in admission suggests possibility of another
stroke (?AICA) as etiology of recent worsening of hoarseness,
swallowing difficulty, and difficulty hearing out of L ear.
MRI/MRA head stroke protocol showed significant cerebrovascular
disease but no change from last MRI [**7-10**].
*
9) NUTRITION: Patient received tube feeds after PEG placement.
Tube feed order at time of d/c was: Probalance Full strength;
Starting rate: 20 ml/hr; Advance rate by 10 ml q6h Goal rate: 55
ml/hr; Residual Check: q4h Hold feeding for residual >= : 150
ml; Other instructions: If residual is >150cc, hold TF for 1
hour. Then restart at 20cc/hr and increase to goal.
*
10) HYPOTHYROIDISM: Continued synthroid. T4 and TSH checked.
*
11) HTN: Well controlled; decreased metoprolol this admission
for episodes of low BP.
*
12) PVD: Continued wound care.  Patient also has erythema over
sacrum and begining to complain of discomfort in that area.
Skin is intact.  Patient turned q2-4 hours.
*
13) PROPHYLAXIS: SQ heparin 5000 U SC TID
*
14) ACTIVITY/PT: [**Name (NI) **] should be OOB to chair daily; PT should
activily follow patient
*
15) FULL CODE


Medications on Admission:
Promethazine HCl 25 mg PO Q6H:PRN nausea
Lactulose 30 ml PO PRN constipation
Lorazepam 0.5 mg PO HS:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN pain
Trimethobenzamide HCl 200 mg IM Q6-8H:PRN nausea
Albuterol Neb Soln 1 NEB IH Q6H:PRN sob
Propoxyphene Nap.-Apap (N-100) 1 TAB PO Q6H:PRN pain
Bisacodyl 10 mg PR QOD
Azathioprine 50 mg PO QD
ASA 325 mg po qd
Citalopram Hydrobromide 30 mg PO QD
Folic Acid 1 mg PO QD
Multivitamins 1 CAP PO QD
Clopidogrel Bisulfate 75 mg PO QD
Prednisone 5 mg PO QD
Finasteride 5 mg PO QD
Sulfameth/Trimethoprim SS 1 TAB PO QD
Levothyroxine Sodium 25 mcg PO QD
Docusate Sodium 100 mg PO BID
Baclofen 15 mg PO TID
Tamsulosin HCl 0.4 mg PO HS
Cyclosporine Modified (Neoral) 100 mg PO Q12H
Insulin SC  (per Insulin Flowsheet) Sliding Scale & Fixed Dose
Pantoprazole 40 mg IV Q24H
Metoclopramide 10 mg IV QAC, QHS


Discharge Disposition:
Extended Care

Facility:
[**Hospital 599**] Healthcare

Discharge Diagnosis:
gastroporesis

Discharge Condition:
stable

Discharge Instructions:
Please return to the emergency room if you experience chest
pain, difficulty breathing, abdominal pain, or high
fever/rigors.  Take medications as prescribed.  Check QID finger
sticks.  Cover with insulin sliding scale, and continue glargine
36 units QHS.

Followup Instructions:
Please follow up with your PCP (Dr. [**Last Name (STitle) 5263**] following discharge
from the hospital within 4 weeks.


MICU NPN 7AM-7PM:
Neuro: Pt very sleepy and tired this AM. Took her pills at 8AM then slept until noon. Woke at that time for her pills and wanted to wait to get up to chair. Seen by team during rounds. After much encouragement pt was assisted OOB to chair at 1PM where she remains at present. She c/o some chest discomfort and was given some relief from the vioxx at noon. She also says that her buttocks are sore from resting in bed so much. I encouraged her to reposition herself frequently and said I would give her a good back rub when she gets back in bed.

Resp: Pt failed attempts to switch her to face shovel mask with 6L N/C O2. She tolerated this for her meals but otherwise wanted the NRB due to dropping her sat with any activity when off the NRB. With the activity of transferring bed to chair her sat dropped to 65% and RR was up to 50. At rest with the NRB her sat is 99% and RR in the 20's. Lungs have coarse breath sounds with some crackles at the bases.

Cardiac: BP and HR stable. Pt given K+ and Mag repletion as ordered.

ID: Afebrile on the ceftaz and clinda.

GI/Heme: Nothing for breakfast and small amt to eat at lunch. No stool today. Heparin drip was held for two hours and restarted at 1400u/hr and repeat PTT was stable at 2PM. She needs another PTT at 8PM tonight to see if her PTT is still within therapeutic range.

GU: Foley draining smalll to mod amts (15-50/hr) drk yellow urine. Team are aware and feel that she is dry and needs time to reequilibrate. Will hold off on diuresis for now.

IV: PICC line dressing changed by IVT today. Looks good. Working well.

Social: No word from pt's family today but she has been on the phone to them on her own.


Admission Date:  [**2189-2-22**]       Discharge Date:  [**2189-3-5**]

Date of Birth:   [**2125-8-2**]       Sex:  F

Service:  NEUROSURGERY

HISTORY OF THE PRESENT ILLNESS:  The patient is a 63-year-old
female with Down's syndrome who presented with difficulty
ambulating, altered mental status, not following commands,
drowsy, and eventually seizures, who was intubated at an
outside hospital after CT showed a 2 cm subdural hematoma on
the right side.  The patient was initially seen in the
Emergency Room and then was taken for a CT and prepared for
surgery.

PAST MEDICAL


HISTORY:


1.  Down's syndrome.
2.  Cellulitis.
3.  Hyperthyroid.

PAST SURGICAL


HISTORY:


Unknown.

ADMISSION MEDICATIONS:
1.  Aricept.
2.  Exelon.
3.  Reminyl 12 mg b.i.d.
4.  Fluoxetine 5 mg q.d.
5.  Depakote 500 mg p.o. b.i.d.
6.  Levoxyl 100 mg p.o. q.d.

SOCIAL


HISTORY:


No alcohol or smoking.  Guardians, [**Name (NI) 9496**]
[**Name (NI) **], [**Telephone/Fax (1) 52444**], and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 52445**].

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  Blood
pressure 148/84, heart rate 82, 100% saturation intubated and
sedated.  Right eye strabismus (blind).  The patient is not
moving any extremities.  Pupil is right trace reaction.  Left
3-2 mm; corneas are intact, localizes bilaterally,
withdrawals bilaterally.  Toes are equivocal.  Poor
examination due to sedation.

LABORATORY/RADIOLOGIC DATA:  A CT of the head on [**2189-2-22**] showed a large right-sided subdural hematoma with
hydrocephalus and .................... of the left lateral
ventricle.

ASSESSMENT AND PLAN:  Subdural hematoma, right side (STH).
The plan is the patient is to have a CT and taken to the
Operating Room for evacuation and stat laboratories.

HOSPITAL COURSE:  The patient was taken to the OR where she
underwent evacuation of the right-sided subdural hematoma and
an ICP drain was placed on the right through the right
parietal bone.  There were no complications.  The patient was
transferred to the Recovery Room and then to the SICU
intubated and sedated with propofol.  A stat CT of the head
the next day, postoperative day number one, showed
improvement of the subdural hematoma with increased mass
affect.

The patient was restarted on her valproic acid and home
medication.  Systolic blood pressure was maintained below
130, and PC02 between 35 and 50.  The patient was n.p.o. with
NG tube and IV fluids, Ancef as prophylaxis.

On postoperative day number one, the patient had a
temperature of 102 and cultures were sent; she was
bronchoscoped.  Each showed bilateral moderate thick
secretions with 50-60% tracheomalacia with no obstruction.
BAL specimen was sent for culture.  Blood culture, urine
culture, and BAL cultures returned negative.

On postoperative day number three, the ICP drain was removed.
On postoperative day number four, the patient was extubated
and placed on face mask CPAP and received aggressive
pulmonary toilet; the patient was able to tolerate tube feeds
(ProMod with fiber, slowly progressing to goal 65 cc an
hour).  Neurologic examination at that point was mildly
improved, she was attempting towards but not following
commands; withdrew all extremities.  The patient had to be
reintubated two days later, postoperative day number six, for
respiratory failure and C02 retention.  Repeat CT on [**2189-2-28**] showed no change and overall improved.

On postoperative day number nine, the patient was extubated
and was placed on face mask and CPAP with stable respiratory
status.  The patient received continuous aggressive
respiratory care with chest percussions.  Physical therapy
started seeing the patient on postoperative day number ten
for mobilization.  The NG tube was removed that day and she
was stable.  She tolerated liquids, although with some
difficulty in swallowing.  On postoperative day number 11
([**2189-3-5**]), the patient could tolerate a regular diet.
She did not require any oxygen.

NEUROLOGIC EXAMINATION ON DISCHARGE:  The patient is awake,
eyes open, turns to voice, verbalizing, and follows commands
partially and localized bilateral upper extremities,
withdraws briskly, right more than left.

DISPOSITION:  To rehabilitation facility for two to three
weeks for physical therapy and continued respiratory care.
Plans to return to group home facility where she was prior to
hospitalization.

DISCHARGE MEDICATIONS:
1.  Albuterol nebulizers one puff q. four hours p.r.n.
2.  Regular insulin sliding scale, as directed.
3.  Dulcolax per rectum p.r.n.
4.  Protonix 40 mg p.o. q.d.
5.  Levoxyl 150 micrograms p.o. q.d.
6.  Valproic acid 750 mg p.o. q.a.m., 500 mg p.o. q.h.s.

CONDITION ON DISCHARGE:  Stable.

RECOMMENDED FOLLOW-UP:  Have a repeat CT of the head without
contrast in two weeks.  The patient is to follow-up with Dr.
[**Last Name (STitle) 1327**] after that (two weeks after discharge).  Please call
for an appointment, [**Telephone/Fax (1) 1669**], as soon as you receive
patient.

DISCHARGE DIAGNOSIS:
1.  Right subdural hematoma, status post evacuation at the
right temple ICP drain placement.
2.  Down's syndrome.
3.  Hypothyroid.
4.  Right eye blindness.



                            [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D.  [**MD Number(1) 1341**]

Dictated By:[**Name8 (MD) **]
MEDQUIST36

D:  [**2189-3-5**]  03:47
T:  [**2189-3-5**]  17:22
JOB#:  [**Job Number 52446**]

 (cclist)


[**2141-4-15**] 11:31 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 72984**]
 Reason: please evaluate placement
 Admitting Diagnosis: FEVER
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


62 year old man with new left subclavian central line.


REASON FOR THIS EXAMINATION:


please evaluate placement
 ______________________________________________________________________________


FINAL REPORT


PORTABLE LINE PLACEMENT, [**2141-4-15**]

 CLINICAL INFORMATION:  New left subclavian central line.


FINDINGS:


Left subclavian catheter terminates in the superior vena cava.  There is no
 pneumothorax.  The lungs are relatively clear with the exception of minimal
 atelectasis at the left lung base.  The cardiomediastinal silhouette is
 unremarkable.


[**2155-7-23**] 10:11 PM
 US EXTREMITY NONVASCULAR RIGHT                                  Clip # [**Clip Number (Radiology) 33754**]
 Reason: R/O GROIN HEMATOMA, PAIN
 Admitting Diagnosis: ACUTE RENAL FAILURE
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


53 year old man s/p vascular surgery of right groin 1 week ago.


REASON FOR THIS EXAMINATION:


r/o groin hematoma
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb WED [**2155-7-23**] 11:25 PM
  Right groin hematoma, measuring 6.4 x 1.6 cm.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


53-year-old man status post right groin surgery.  Rule out right
 groin hematoma.


COMPARISON:


None.


FINDINGS:


Grayscale and Doppler evaluation of right groin demonstrates a
 right groin hematoma measuring 6.4 x 1.6 cm without internal vascularity.  The
 underlying common femoral artery and common femoral vein demonstrate normal
 color flow.  [**Name (NI) 33755**] son[**Name (NI) 782**] scanning demonstrated normal arterial and
 venous waveforms, however, these images are not available on PACS for review.


IMPRESSION:


Hematoma without evidence for pseudoaneurysm.
                                                                       SESHa


Neonatology Attending Progress Note
Now day of life 34, CA [**04**] 4/7 weeks.
On vent support of 24/7 20 and pressure support of 10, FIO2 40-44%
RR - 30-60s
On caffeine.
No apnea/bradycardia - occasional desaturation episodes.
CVS - HR - 150-170s  BP 68/46 52
Lasix MWF and albuterol Q6H

Wt. 1520gm up 10gm on 130ml/kg/d of MM30 with Beneprotein or PE30 with Beneprotein.
Normal urine output - no stool in 3 days.

Assessment/plan:
Almost 5 week old infant with evolving CLD.  FIO2 requirement is slightly decreased and less
Will continue with current regimen.
FU blood gas in 2 days.


Neonatology Attending
DOL 29 / PMA 36-5/7 weeks

In room air with no cardiorespiratory events.

Murmur. BP 76/39 (53).

Wt 2545 (+50) on TFI 150 ml/kg/day BM26/SC26, tolerating well PO/PG. Abd benign. Voiding and stooling normally (guaic negative)

A&P
32-4/7 week GA twin with feeding immaturity
-Continue to await maturation of oral feeding skills
-Follow murmur clinically (preliminary investigations negative)


PATIENT/TEST INFORMATION:


Indication:


Left ventricular function.
Weight (lb): 134
BP (mm Hg): 92/50
HR (bpm): 96
Status: Inpatient
Date/Time: [**2105-6-23**] at 14:10
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: Normal LA size.

LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Moderately
depressed LVEF. TVI E/e' >15, suggesting PCWP>18mmHg. TVI e'<0.08m/s c/w
elevated LV filling pressures. No resting LVOT gradient. No LV mass/thrombus.
No VSD.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic root diameter. Focal calcifications in aortic root.
Normal ascending aorta diameter. Focal calcifications in ascending aorta.

AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve
leaflets. Mild AS. Mild (1+) AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Mild mitral
annular calcification. Moderate thickening of mitral valve chordae. Calcified
tips of papillary muscles. Cannot exclude MS. Moderate (2+) MR. LV inflow
pattern c/w impaired relaxation.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal
tricuspid valve supporting structures.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with
physiologic PR. Normal main PA. No Doppler evidence for PDA

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium is normal in size. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is moderately-to-severely depressed
(ejection fraction 30 percent) secondary to severe hypokinesis of all walls
except the posterior wall, with apical akinesis. Tissue velocity imaging E/e'
is elevated (>15) suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Tissue velocity imaging demonstrates an e' of <0.08m/s c/w an
elevated left ventricular filling pressure (>12mmHg). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There are three
aortic valve leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is no mitral valve
prolapse. There is moderate thickening of the mitral valve chordae. The study
is inadequate to exclude significant mitral valve stenosis. Moderate (2+)
mitral regurgitation is seen. The left ventricular inflow pattern suggests
impaired relaxation. There is no pericardial effusion.


NEURO-INTACT. MAE.PERLA.

CV-NSR-ST. RARE PVC. NO GTTS. BP STABLE. NO ISSUES.

RESP- 2LNC=97%. RA=93%. LSC.CT WITH SCANT SS DRG.

G.I.-ABD SOFT. +BS.

G.U.- DIURESED WELL FROM 20MG IVP LASIX. FOLEY INTACT.

PAIN-DILAUDID PCA WITH GOOD PAIN RELIEF.

PLAN-TRANSFER TO [**Hospital Ward Name 57**] 2 TODAY. OOB TO CHAIR,AMBULATE.


CCU NPN 3-11pm
CV: pt denies CP, has SOB with exertion in bed, just repositioning. LS clear, sats 95-98% on 3L NC. HR 100-120's went into a.fib ~1530, given 2.5mg IV lopressor x2 and increased to 12.5mg po tid(from [**Hospital1 **]), Has had intermittent short runs of NSR but back to a.fib(ECG done, rhythm irregular, possibly could be atrial tachycardia with freq apc's), no hep gtt d/t recent?RV perf vs bloody pericarditis. Then given 10mg IV dilt with slowing of HR to 90's-100, again intermittent NSR, Dilt gtt to start at 5mg/hr. BP has been 120-130's/60, cont on Nipride at 0.8mcg/kg/[**Last Name (LF) 217**], [**First Name3 (LF) **] try to wean off as dilt started.
PAD 15-20, CVP 12-17, CO/CI 5.6/3.44 SVR 929, mixed venous sat 63%.
Cont to have pulsus paradox of 15-20. Echo this AM without increased effusion. R groin without bleeding or hematoma, DP's weak bilat, PT +3 bilat.

Resp: as above, pt did request neb which she got at [**2200**]. She finds it difficult to lie down, bed in rev-trend and hob raised sl.

GU: given 40mg IV lasix with unit PRBC's, diuresed well, -3400cc today, repeat lytes pnd.

Heme: HCT just 1 hr after transfusion was 31.0

GI: appetite fair, eating sm amts, no BM, on colace, states she won't be able to use bedpan. Last BM was Friday.

ID: low grade T too 100.3

Neuro: MAE, equal strength bilaterally. She feels L side is back to normal. Pt is A&Ox3.

soc: Daughter [**Name (NI) **] in most of afternoon, [**Doctor First Name 1584**] in this eve, updated by RN. Need SS consult for altered family dynamics, assess home needs. [**Doctor First Name 1584**] stated mother has not been taking medication at home as ordered d/t financial concerns.

A/P: 81 yr old s/p MI, ?RV rupture initially with tamponade, pericardial drain. Drain out as of yesterday, pt has had episodes a.fib, today had HTN and return of neuro smp. Swan left in place given recent events. Cont to monitor closely overnight, Start IV dilt for rate control. Cont to support pt/family, SS consult.


Nursing Status/Progress Note 7A-7P


#3,12 TF remain at 140cc/k/d. Is NPO, PIV infusing D10TPN +
IL, D/S 79. Voiding well, stooled dark green guiaic positive
this AM. Girth is 21.5-22.5 so far this shift, and abdomen
is soft and round with transient soft loops. Had abdominal
ultrasound this AM, are ruling out ulcer at this time and GI
has been in to consult. Planning on obtaining PT/PTT today
and will have Zantac put in PN this evening. Hct:29.4,
essentially unchanged from 1AM. No murmur heard, HR
140-160's, is pale-pink and mottling at times. Plan as per
status/ultrasound results, and blood work results.

#4 Maintaining temp on servo-warmer with photo tx, is very
active with handling and settling well afterward. Likes to
suck on pacifier. HUS done this AM, results pending. Con't
present interventions.

#5 Mom called this AM re:infant's status and was updated,
was also pleased with his activity. Would like US results
when available, and [** **] plan on visiting this evening;
would like to hold [**Known lastname **] if possible. Con't to update,
possibly call mom when results available.

#7,9 Has has 3 brady's with apnea so far this shift, HR
40's, desat's to 80's requiring mild stim. Remains on nasal
cannula 200cc's 21%, LS = and clear, transient retractions.
RR's 30-60's. On caffeine. Con't to monitor closely.

#10 Remains on gent and vanco, planning to treat for total
of 7 days. CBC w/diff have been unremarkable for sepsis,
blood culture to date has been negative. Con't to monitor.

#11 Bili this AM: 8.7/0.5. Remains under triple photo tx
with eye and genital protection in place. To check a bili at
12 noon. TF at 140cc/k/d. Infant active w/handling. Plan as
per bili results.


60 year old male admitted to [**Hospital1 5**] for a T11-L5 fusion for pt
   scoliosis. Past medical hx of hiatal hernia repairs, hepatitis, long
   time smoker, irritable bowel syndrome, depression and panic attacks.
   OR:
                   ~ [**11-10**] anterior fusion of T11
                   ~ [**11-13**] posterior fusion of T11-T5
   *Pt lost 3 liters of blood during 2^nd surgery and was resuscitated
   with 7 units PRBCs and 2 units of FFP. Pt extubated and then
   reintubated after surgery because of MS changes.  Pt thought to have
   aspirated into Right Lower Lobe.
   -Neo gtt for pt
s hypotension s/p second spinal fusion surgery.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 76**])
   Assessment:
   Pt on SIMV with adequate ABG and O2 saturations. Minimal secretions. LS
   clear. Pan Cultures done [**11-14**] and pending.
   Action:
   Pt on Vanco and Zosyn started for ?aspiration PNA. Chest xray taken.
   Changed Pt to PS 10 Peep 8 Fio2 of 60%. Pulmonary toileting
   Response:
   Pt O2 sats wnl and ABG wnl. Pt weened to Fio2 of 50%. Secretions
   increased (thick, yellow)
   Plan:
   Continue pulmonary toileting. Wean vent settings. Monitor ABG and O2
   sats.
   Fever, unknown origin (FUO, Hyperthermia, Pyrexia)
   Assessment:
   Pt Tmax of 101.6 and Increased WBC
   Action:
   Pt on Vanco and Zosyn. Tylenol given. Fan placed in room.
   Response:
   Pt decreased temp and WBC decreased.
   Plan:
   Monitor Pan culture results from [**11-14**]. Give Tylenol as needed. Monitor
   temps.
   Acute Pain
   Assessment:
   Pt HR in 90s and increased to 130s with turning and suctioning. RR
   increased. Pt on fentanyl gtt at 150mcg/hr. Pt localizes to pain.
   Action:
   Pt changed to Fentanyl gtt of 200mcg/hr due to pt not settling after
   activity and HR and BP elevated. Ativan IV given q2h and Propofol gtt
   started.
   Response:
   Pt HR decreased to 80s -90s and BP decreased with more sedation. RR
   wnl. Pt appears more comfortable.
   Plan:
   Continue to monitor pain and vital signs. Wean off propofol and change
   to just ativan IV.


42 yo man pedestrian vs car +ETOH +LOC found unresponsive with FS 20-30
   given d50 and transferred [**Hospital1 19**]. Injuriens R humeral neck fx displaced,
   R greater trochanteric fx, b/l superior rami fx, R inf rami fx, ? L inf
   rami fx, L2-3 TP fx, ant compression deformity T4. Ortho deferred
   surgery due to elevated INR of 1.5. Hct had fallen from 26.9 to 19
   [**2179-2-8**] he was transfused 2 uprbc. He had a CT of torso which did not
   show hematoma and he was transferred to TSICU for closer monitoring. He
   also had a change in MS on the floor CIWA scale in place.
   Delirium / confusion
   Assessment:
   Auditory and visual hallucinations, very agitated at times, restless,
   suspicious, ciwa scale 20. Pupils equal and reactive, mae, fc. Pt
   grimacing to movement especially of his left leg. Left leg ant calf
   area of 4x2cm edematous, erythematous and ankle, foot edematous 2mm >
   than right pedal pulses +
   Action:
   Tx per ciwa scale with ativan 1mg IV. Tx with 1mg iv dilaudid for pain
   Response:
   Ciwa scale < 10, able to move in bed with less pain
   Plan:
   Monitor ciwa scale tx prn, medicate for pain, monitor area on left leg
   MD [**First Name (Titles) 1485**]
[**Last Name (Titles) 5008**]mia (Volume Depletion - without shock)
   Assessment:
   Hct 29.2 after 2uprbc, bp stable INR 1.2
   Action:
   Checking hct INR
   Response:
   Hct stable
   Plan:
   Monitor hct, hr, bp, INR
   Hypoglycemia
   Assessment:
   Blood sugars 141, 164
   Action:
   Tx per ss insulin
   Response:
   Plan:
   Tx per ss insulin check FS q 6


0700-1900 NPN
See carevue for subjective/objective data.
Neuro:  This AM pt anxious, blinking "yes" when asked if she is having trouble breathing.  Med with Morphine in increasing amounts with effect.  Since this AM pt has not required further Morphine-->sleeping but arousable to tactile and verbal stimuli but is not able to stay awake long enough to blink "yes" or "no".  Last dose Morphine given at 0915.

CV/Pulm:  MP remains NSR, no ectopy noted.  VSS.  R TLC patent, IV's infusing at KVO.  Remains on face mask at .40% with sats 91-93%.  BS diminished bil.  Resp's shallow this afternoon.

GI/GU:  Abd soft, non-tender, bowel sounds present.  To start on TF this evening as [**Name8 (MD) 52**] MD orders.  Colostomy draining brown liquid in small amounts.  U/O qs q2h via foley.

ID/Integ/Psychosocial:  Afebrile.  Remains on triple abx.  Both feet with DSD's intact, multi-podis boots remain on.  HCP in to visit, spoke with [**Name (NI) 10918**] is aware that pts prognosis is poor.  Emotional support given to pt and HCP.

Plan:  Cont abx, medicate with morphine prn.  Pt is DNR/DNI.  Cont current regime.


Admission Date:  [**2172-3-23**]              Discharge Date:   [**2172-3-31**]


Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive


Procedure:


Upper Endoscopy
Colonoscopy
Tunnelled Hemodialysis Catheter


History of Present Illness:
84 yo man with a PMH significant for CAD, AFib, ESRD on HD, PVD,
severe mitral regurg who p/w BRBPR.  He was recently
hospitalized at the [**Hospital1 **] in [**2-2**] for incision and drainage of a
left foot hematoma. He was discharged to rehab on [**2172-2-24**] where
he subsequently required intermittent blood transfusions.
During the 24 hours prior to admissions, his Hct dropped from 28
to 24 and was noted to have several episodes of grossly bloody
stools with large clots. He received NS and 1 units PRBCs with
repeat Hct of 21. He was sent to [**Hospital1 **] for further management.
.
In the ED, his pulse was 70 and his bp was 130s/70s. His stool
was guaiac positive. No NG lavage was done. He was not
transfused due to multiple antibodies. He was given protonix,
vanco, levo, and flagyl.
.
He was admitted to the MICU for further care. NG lavage was
negative. Has received 2 units of PRBC since admission with Hct
stable for the past 24 hours, 25.3-28.5.
.
[**Hospital1 4273**] chest pain, SOB, dizziness, abdominal pain.


Past Medical


History:


1)ischemic cardiomyopathy w/severe LV systolic dysfunction with

EF of 30%
2)CAD
3)severe mitral regurgitation
4)Atrial fibrillation, s/p ICD-not anticoagulated
5)Peripheral [**Hospital1 1106**] disease, s/p bypass leg surgery
6)ESRD on HD T/H/S (via R subclav permacath)
7)Anemia on Procrit and iron supplementation
8)? CVA [**90**] years ago with left facial numbness
9)Hypothyroidism
10) s/p right above the knee popliteal bypass graft in [**2160**] and

a left femoral popliteal artery bypass graft with revision that

included the left femoral to anterior tibial artery jump graft
in [**2167**]


Social


History:


Smoked 1 ppd x 50 yrs, quit [**2163**]. Reported heavy EtOH use in
past, none currently.  currently at [**Hospital1 **]. Lives with his
wife in [**Name (NI) **]. 2 children living in [**State 8449**].Retired
maintenance worker at [**Hospital3 **].


Family


History:


NC

Physical


Exam:


T: 96.9 BP: 172/45 P: 78 R: 21 100% on 2LNC
24 hour I/O: 2920/2168
Gen: elderly male in NAD, lying comfortably in bed
HEENT: NC, AT, anicteric, MM dry
Neck: supple
Lungs:  Rales on left lower base.
CV: RRR, holosystolic systolic murmer heard best at the right
sternal border
Abd: soft, nt/nd, +bs
Ext: No edema
Skin: eccymosis on arms.  Tophi on toes bilaterally.  Dressing
over left foot.


Pertinent Results:
Admission Labs:
[**2172-3-23**] 04:25AM BLOOD WBC-6.8# RBC-2.64* Hgb-8.4* Hct-25.0*
MCV-95 MCH-32.1* MCHC-33.8 RDW-17.3* Plt Ct-159
[**2172-3-23**] 04:25AM BLOOD Neuts-72.9* Lymphs-18.3 Monos-4.5 Eos-3.9
Baso-0.4
[**2172-3-23**] 04:25AM BLOOD PT-13.1 PTT-33.3 INR(PT)-1.1
[**2172-3-23**] 04:25AM BLOOD Glucose-97 UreaN-54* Creat-3.8* Na-136
K-4.6 Cl-105 HCO3-21* AnGap-15
[**2172-3-23**] 04:25AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0
[**2172-3-26**] 06:19AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.7
[**2172-3-29**] 04:37AM BLOOD Cortsol-13.3
.
Most Recent Labs:
[**2172-3-31**] 09:02AM BLOOD WBC-5.1 RBC-3.22* Hgb-10.4* Hct-30.0*
MCV-93 MCH-32.2* MCHC-34.5 RDW-18.6* Plt Ct-152
[**2172-3-31**] 09:02AM BLOOD Plt Ct-152
[**2172-3-31**] 09:02AM BLOOD Glucose-87 UreaN-38* Creat-4.6* Na-137
K-3.9 Cl-102 HCO3-24 AnGap-15
[**2172-3-30**] 05:43AM BLOOD Calcium-7.6* Phos-3.8 Mg-2.0
.
.
Tagged RBC scan on [**2172-3-23**]:
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 60 minutes were obtained.  A left lateral view of
the pelvis was also obtained.    Blood flow images show
increased tracer activity in the left upper quadrant  which is
due to uptake in an enlarged spleen.  Dynamic blood pool images
show no evidence of active gastrointestinal bleeding.


IMPRESSION:


No active gastrointestinal bleeding identified.
Splenomegaly.
.
Chest X-ray on [**2172-3-23**]:
The left-sided [**Date Range 4448**] is seen with leads in unchanged
position.  A right hemodialysis line is seen with tip in the
superior vena cava.  The cardiomediastinal silhouette is within
normal limits.A left retrocardiac opacity is less conspicuous on
the current examination.


IMPRESSION:


1.  Left retrocardiac opacity has minimally improved and may
represent
atelectasis or pneumonia.
.
Upper endoscopy [**2172-3-25**]:
Erythema, edema, friability in the stomach body, antrum and
pylorus compatible with Severe gastritis
Erosions in the stomach body
Small hiatal hernia
Otherwise normal EGD to second part of the duodenum
.
Colonoscopy [**2172-3-25**]:
Diverticulosis of the sigmoid colon and descending colon
Polyps in the Throughout the colon
Angioectasias in the cecum
Otherwise normal colonoscopy to cecum


Brief Hospital Course:
.
# GI BLEED: Patient initially admitted to MICU due to dramatic
hematocrit drop.  This subsequently stabilized after 2 units
PRBC transfusion.  NG lavage was negative.  Patient was prepped
and underwent esophagogastroduodenoscopy and colonoscopy.  EGD
showed severe gastritis and colonoscopy showed numerous
diverticuli and adenomatous polyps.  Tagged RBC scan was
negative.  Likely multifactorial bleed due to above 3 causes,
with diverticular bleed probably greatest contributor.  The
patient's hematocrit was relatively stable throughout the
hospital stay. The patient received 2 more units of PRBCs.
Patient is scheduled for follow-up with GI as an outpatient for
removal of polyps.  H. pylori antibody test was positive.
Triple therapy with PPI, amoxicillin, and clarithromycin (all
renally dosed) was strated on [**2172-3-30**] to be continued for a total
of 14 days.
.
# C. DIFF: Patient developed diarrhea on hospital day 5. It was
thought that the diarrhea was likely secondary to C. diff and he
was emperically started on metronidazole on [**2169-3-29**]. C. diff
toxin assay was sent and subsequently came back positive [**2172-3-29**].
 He should continue on flagyl for at least 7 days beyond H.
pylori triple therapy.
.
# HYPOTENSION: Patient was initially hemodynamically stable on
presentation, and in fact, became hypertensive later in MICU
course.  His home regimen of antihypertensive was therefore
restarted as follows: Hydralazine, Valsartan, Metoprolol. Imdur
was restarted on [**2172-3-25**]. On hospital day 5 the patient had
hypotensive episode with systolic BP between 80-90.  Fluid was
given and BP medications were held to maintain stable systolic
blood pressure >120. It was thought that the hypotensive episode
was due to hypovolemia secondary to 1.6 kg fluid removed during
hemodialysis earlier that day, as well as significant volume
depletion secondary to his diarrhea from C. Diff.  No further
hypotensive episodes were noted after fluid resuscitation.
.
# FEVER: On hospital day 5, patient had fever of 101.  His fever
was thought to be secondary to C. diff infection, as diarrhea
was present at that time (see above).  Blood cultures were
negative for several days, and still pending at the time of
discharge.  His temperature normalized after initiation of
Flagyl for C. diff.
.
# A FIB: Patient has a [**Date Range 4448**]. Rate was stable and he was
continued on amiodarone.
.
# ESRD: Patient was dialyzed Tu/Th/Sa via subclavian permacath.
His HD catheter was repositioned on this admission.  He was
continued on nephrocaps, erythropoietin at dialysis and
neurontin.  The renal service followed him throughout this
admission. Next HD session planned for Friday, [**4-3**].
.
# LEFT FOOT HEMATOMA: s/p I&D on his last admission by [**Month (only) 1106**]
surgery.  He was continued Papain and becaplermin.  He will
follow up with [**Month (only) **] as previously scheduled as an
outpatient.
.
# HYPOTHYROIDISM: Continued levothyroxine
.
# ACCESS: PICC placed prior to this admission.  Also had
peripheral IV, and HD cath.  Tunnel line catheter cuff was found
to be exposed on [**2171-3-25**] and a new line was placed by IR on
[**2172-3-25**].  PICC line was pulled prior to discharge.
.
# CODE STATUS: Full
.
# DISPO: patient was discharged to rehab in stable condition on
[**2172-3-31**].
.
.

Medications on Admission:
morphine 3 mg IV q2h:prn
tylenol prn
albuterol neb prn
tylenol w/codeine prn
glycerin supp prn
senna prn
trazodone 25 mg qhs
valsartan 80 mg daily
hydralazine 25 mg q6h
toprol 125 mg daily
nephrocaps
nystatin 6 ml po tid
accuzyme ointment to foot daily
insulin sliding scale
imdur 30 mg daily
levothyroxine 125 micrograms daily
colace 100 mg tid
neurontin 300 mg q48h
aztreonam 0.125 grams q6h and at hemodialysis TIW
becaplermin to wound daily
epo at HD
amiodarone 200 mg daily
aspirin 325 mg daily
atorvastatin 20 mg daily

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
PRIMARY:
1) GI bleeding
2) C. Difficile infection
3) H. Pylori
4) End-stage renal disease on HD
5) Hypotension
SECONDARY:
1) Atrial fibrillation
2) Left foot hematoma


Discharge Condition:
Stable, improved from the time of admission


Discharge Instructions:
Please call your doctor or go to the ER if you experience any
worsening of your diarrhea, fever/chills, dizziness,
nausea/vomiting, abdominal pain, or any other concern.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet


Followup Instructions:
1) [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2172-4-9**] 8:00; E
SUITE GI ROOMS Date/Time:[**2172-4-9**] 8:00
2) [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2172-4-15**]
3:15
3) Please call the radiology department to set up a Small-Bowel
follow through.  Call [**Telephone/Fax (1) 327**] for an appointment.
4) Please call your primary care doctor for a follow up
appointment after discharge from rehab.


85 YEAR OLD [**Hospital **] transferred from OSH [ [**Doctor Last Name 5888**]]here since [**1-5**] -
   began with DVT [ previous DVT had IVC filter placed], received
   anti-coagulation which led to CVA/ SDH and seizures.Patient acute on
   chronic renal failure now requiring HD [ last HD on Wednesday.PEG
   placed 2 days ago, intermittent hypotension since, requiring IVF, belly
   tense
CT tense showed intra-adbo fluid and lots of free air
.foley
   placed by urology yesterday via cysto [ known bladder CA], pt usually
   makes approx 200cc urine per day
x2uprbcs yesterday [ ? transfusion
   reaction with second unit], pt has been febrile overnight and
   hypotension to 50
s..transfer to MICU for possible sepsis ? UTI/ belly
   as source
   EVENTS
.patient has received total 1l n/ saline for tachycardia > 100,
   morphine , ativan for pain/restlessness, lactate stable < 2.0
.repeat
   CT scan of belly done, results pending [ surgery following]
.NPO at
   present
ABS for possible UTI,
vascular following for gangernous toes on
   rt
   .H/O abdominal pain (including abdominal tenderness)
   Assessment:
   Action:
   Response:
   Plan:
   Urinary tract infection (UTI)
   Assessment:
   Action:
   Response:
   Plan:
   .H/O CVA (Stroke, Cerebral infarction), Hemorrhagic
   Assessment:
   Action:
   Response:
   Plan:


Probable sinus tachycardia with atrial premature beat but baseline artifact
makes assessment difficult. Inferolateral lead ST-T wave changes are
non-specific. No previous tracing available for comparison.
TRACING #1


Pain control (acute pain, chronic pain)
   Assessment:
   POD#2 s/p transphenoidal resection of pituitary tumor, pt awake, alert
   OX3. EOM lateral gaze of left eye and horizontal nystygmus both eyes
   noted. noted. Pt has intact peripheral vision. Pupils 5mm each briskly
   reactive. MAE equally. No pronator drift . Pt has had pain [**8-11**]
   headache at [**2123**]. Pt has hx of taking PO dilaudid at home 2-4mg PO q3-4
   6rs. Bilateral breath sounds clear, foley to BSD, abd incision RLQ
   clean and dry sutures intact . Skin otherwise intact. Nasal trumphet rt
   nare and fat packing from abd in left nare.
   Action:
   Urine output and q 4 hr serum and urine osmolality  done.
   Pain management with IV dilaudid
   Response:
   Stable labs and u/o
   Plan:
   Transfer to SDU when bed available
   Call [**3-/3036**] for u/o>250ml/hr and specific gravity of urine <1.005,
   serum osmo 295 or higher NA 145.
    Continue to medicate for headaches with dilaudid.


Sinus rhythm with probable aberrantly conducted atrial premature beat. Left
ventricular hypertrophy by voltage criteria with non-specific ST segment
abnormalities in the inferolateral leads. QS complex in lead V1 with a notched
QRS complex in lead V2. Compared to the previous tracing of [**2152-3-16**] the rate is
faster and almost tachycardic. Left ventricular hypertrophy is less apparent.
Frontal plane axis is less leftward. QS complex in lead V1 is unchanged.
However, QRS morphology in lead V2 is different suggesting interval differences
in electrode placement. T wave amplitude is flatter throughout with
accentuation of the repolarization abnormalities. Repolarization abnormalities
may be due to left ventricular hypertrophy. However, an ischemic process cannot
be excluded. Clinical correlation is suggested.
TRACING #1


Sinus bradycardia, rate 47.  Low voltage in the limb leads.  Q-T interval
prolongation.  Compared to the previous tracing of [**2200-3-18**] the non-specific
ST segment changes noted laterally, at that time, have regressed.  The rate
is slower.  The Q-T interval has prolonged further.  No other diagnostic
interval change.


TSICU
   HPI:
   HPI:64M w/well-differentiated liposarcoma right retroperitoneum, s/p
   rsxn x3 since [**2177**], s/p right nephrectomy, partial adrenalectomy and
   colectomy s/p radiation therapy, now s/p.....on [**3-8**]
   .
   ISSUES:liposarcoma resection, abdominal distension
   .
   CHIEF COMPLAINT:R retroperitoneal liposarcoma
   .
   CURRENT MEDICATIONS:Insulin SC, LR at 125 ml/hr, Levofloxacin 500 mg IV
   Q24H, Magnesium Sulfate IV Sliding Scale, Calcium Gluconate  IV Sliding
   Scale, MetRONIDAZOLE 500 mg IV Q8H x 3 Doses, Chlorhexidine Gluconate
   0.12% Oral Rinse 15 ml ORAL [**Hospital1 **], Metoprolol 5 mg IV Q4H, Clindamycin
   600 mg IV Q8H x 3 Doses, Pantoprazole 40 mg IV Q24H,
   Fentanyl Citrate 25-100 mcg/hr IV DRIP, Potassium Chloride  IV Sliding
   Scale, Heparin 5000 UNIT SC TID, Propofol 20-100 mcg/kg/min IV DRIP
   TITRATE TO sedation, Influenza Virus Vaccine 0.5 mL IM, atrovent INH
   2puffs Q6H PRN
   .
   EVENTS:
   .
   24 HOUR EVENTS: [**3-8**]: OR for liposarcoma resection, to TICU intubated,
   bladder pressure 20, got 2u PRBCs, marginal UOP on admission - improved
   over night
   .
   MEDICAL:Recurrent liposarcoma, OSA, HTN, HLD, DM, BPH, COPD, Memory
   deficits status post head trauma from MVA, s/p TURP
   .
   [**Last Name (un) **]:Atenolol 25', Citalopram 20', Diltiazem 120', Doxazosin 4', Lantus
   25', Metformin 1000', Benicar 20', Actos 30', Simvastatin 40', ASA 81',
   Omeprazole 20', Ped MVI 0.4 mg-300 mcg-250 mcg Tablet
   .
   SURGICAL Hx:prior liposarcoma resection x3, TURP
   .
   SOCIAL Hx: retired, smokes 1ppd, no EtOH, former warehouse employee
   .
   ALLERGIES:PCN
   .
   EKG:
   .
   ABX: gent, levo, flag x24h (small enterotomy)
   .
   MICRO:
   .
   IMAGING:
   [**3-8**] CXR: RIJ CVL in good position, no acute process
   Chief complaint:
   PMHx:
   Current medications:
   24 Hour Events:
 OR RECEIVED - At [**2192-3-8**] 05:38 PM
 ARTERIAL LINE - START [**2192-3-8**] 05:38 PM
   placed in OR
 CORDIS/INTRODUCER - START [**2192-3-8**] 05:38 PM
   placed in OR
 INVASIVE VENTILATION - START [**2192-3-8**] 05:38 PM
 EKG - At [**2192-3-8**] 08:57 PM
   Post operative day:
   POD#1 - radical resection of retroperitoneal sarcoma
   Allergies:
   Penicillins
   Hives;
   Last dose of Antibiotics:
   Levofloxacin - [**2192-3-8**] 08:00 PM
   Metronidazole - [**2192-3-9**] 04:00 AM
   Clindamycin - [**2192-3-9**] 06:00 AM
   Infusions:
   Propofol - 30 mcg/Kg/min
   Other ICU medications:
   Pantoprazole (Protonix) - [**2192-3-8**] 08:37 PM
   Heparin Sodium (Prophylaxis) - [**2192-3-9**] 04:00 AM
   Fentanyl - [**2192-3-9**] 06:00 AM
   Other medications:
   Flowsheet Data as of  [**2192-3-9**] 07:39 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**95**] a.m.
   Tmax: 37.2
C (98.9
   T current: 37.2
C (98.9
   HR: 84 (61 - 90) bpm
   BP: 98/50(65) {80/42(53) - 113/56(76)} mmHg
   RR: 18 (12 - 22) insp/min
   SPO2: 95%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 63 Inch
   CVP: 15 (15 - 19) mmHg
   Bladder pressure: 19 (16 - 20) mmHg
   Total In:
                                                                 10,961 mL
                                                                  2,335 mL
   PO:
   Tube feeding:
   IV Fluid:
                                                                  7,829 mL
                                                                  2,138 mL
   Blood products:
                                                                  3,132 mL
                                                                    198 mL
   Total out:
                                                                  1,262 mL
                                                                    431 mL
   Urine:
                                                                    112 mL
                                                                    231 mL
   NG:
                                                                    200 mL
   Stool:


Neonatology Attending Progress Note


Addendum - PE

Baby is [**Name2 (NI) 211**] centrally.
AF soft and flat.
Lungs clear and equal.
CVS - S1 S2 normal - no murmur
Abd - benign
Neuro - tone overall decreased today.


Sinus rhythm.  Non-specific ST-T wave changes.  There is variation in
precordial lead placement.  The previously mentioned findings recorded
on [**2120-10-11**] persist without diagnostic interim change.
TRACING #3


NURS


I agree with the above note by [**First Name8 (NamePattern2) 1693**] [**Doctor Last Name **] CoWker.[**Doctor Last Name 1**] [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2**] here for exam and updated.


[**2140-11-1**] 8:36 AM
 CT CHEST W/CONTRAST; CT ABD W&W/O C                             Clip # [**Clip Number (Radiology) 39151**]
 CT PELVIS W/CONTRAST
 Reason: evaluate response to treatment
 ______________________________________________________________________________
                                 FINAL ADDENDUM
 We have been asked to compare this examination with prior outside studies,
 uploaded to PACS since this scan was performed. This examination is being
 compared to the CT examination of [**2140-4-6**], from [**Hospital **] Hospital in [**Location (un) 39152**].
 Two other examinations uploaded to PACS, CT's from [**2137-5-7**] and [**2140-6-9**] are less
 comparable as they were not preformed with contrast enhancement.

 Comparison of the hepatic lesions demonstrate no appreciable change in size of
 these lesions, allowing for differences in technique. The lesion previously
 described in the right posterior lobe of the liver is again seen (3:58) with
 enhancement, and given difference in post-contrast phase of imaging, is again
 suggestive of hemangioma. Other hypodensities are unchanged. Large ventral
 hernia is new since 2/[**2140**].


 [**2140-11-1**] 8:36 AM
 CT CHEST W/CONTRAST; CT ABD W&W/O C                             Clip # [**Clip Number (Radiology) 39151**]
 CT PELVIS W/CONTRAST
 Reason: evaluate response to treatment
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


57 year old woman with stage III ovarian cancer- s/p chemotherapy


REASON FOR THIS EXAMINATION:


evaluate response to treatment
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATIONS:  57-year-old woman with stage III ovarian cancer, status post
 chemotherapy.

 COMPARISONS:  None available.


TECHNIQUE:


Axial CT images of the chest, abdomen, and pelvis were obtained
 with both oral and intravenous contrast, following acquisition of a non-
 contrast series of the abdomen.  Additional delayed phase imaging through the
 kidneys only was performed, as well as sagittal and coronal reconstructions.

 CHEST WITH IV CONTRAST:  There are coronary artery calcifications.  The heart
 is normal in size.  There are no pleural or pericardial effusions.  Several
 small mediastinal lymph nodes are present including a precarinal node that
 measures 12 x 7 mm in axial dimensions (3:23) and may be partly calcified.
 There is mild bibasilar atelectasis and/or scarring.  The lungs are clear.

 CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: There are several hypodense
 foci in the liver that are too small to characterize (3:58, 57, 53, 62).  All
 are less than 10 mm in diameter.  Although most likely benign lesions such as
 cysts and hemangiomas, the less likely possibility of metastases cannot be
 fully excluded.

 The gallbladder, pancreas, spleen, adrenal glands, and left kidney are within
 normal limits.  There is focal scarring along the anterior lower pole of the
 right kidney and a hypodense focus in the interpolar region of 7 mm in
 diameter, too small to characterize.  There is a ventral hernia containing
 non-obstructed colon and small bowel.  There is no mesenteric or
 retroperitoneal lymphadenopathy, or ascites.  There are no suspicious
 mesenteric findings or stranding.

 CT OF THE PELVIS WITH IV CONTRAST:  The rectum, sigmoid, and bladder are
 unremarkable.  The patient is status post hysterectomy.  There is no pelvic
 lymphadenopathy or free fluid.

 BONE WINDOWS:  There are no suspicious lytic or blastic lesions.


IMPRESSION:


No definite evidence for recurrent or metastatic disease, although
 several small liver lesions are observed.  Although likely benign, given the
 known primary malignancy, an MR could be performed to confirm benignity of the
 lesions given its better sensitivity for characterizing cysts and hemangiomas.
                                                             (Over)

 [**2140-11-1**] 8:36 AM
 CT CHEST W/CONTRAST; CT ABD W&W/O C                             Clip # [**Clip Number (Radiology) 39151**]
 CT PELVIS W/CONTRAST
 Reason: evaluate response to treatment
 ______________________________________________________________________________


FINAL REPORT


(Cont)


NPN

Neuro:  Pt is alert, following commands via gestering by us, he was OOB to a chair for 1 hr today, he needed 2 people for help but was able to do most of the work on his own.

CV:  BP stable, he is now on standing lasix.

Resp:  He conts on the trache collar, he still has high suctioning requirements for thick light yellow sputum.  He had a passey [**Last Name (un) 1144**] valve placed today, he lasts about 1 hour before he needs to have it  taken off so he can be suctioned.

GI:  Conts on TF, his wt was 44.0 kg and his his TF rate was increased to 55cc/hr.  No BM today - he was given his bowel meds.

GU:  Started on QD lasix via his GT.

Soc:  He is ready for rehab, he has a bed at [**Hospital1 2**] but the family wants him to be near [**Location 1145**].


Sinus bradycardia with sinus arrhythmia, A-V conduction delay and atrial
premature beat. Probable intra-atrial conduction delay. Anterior wall
myocardial infarction with ST-T wave configuration consistent with acute
process. Low QRS voltage is non-specific. Since the previous tracing
of same date right bundle-branch block and left anterior fascicular block are
now absent, further evolution of precordial lead Q waves is present, ST-T wave
abnormalities are less prominent and QRS voltage is lower.
TRACING #2


TSICU PROGRESS NOTE
NEURO: ALERT AND ORIENTED X 3 FOLLOWING ALL COMMANDS STRENGTH EQUAL THROUGHOUT UPPER AND LOWER EXTREMITIES DENIES NUMBNESS OR TINGLING PUPILS 3 BRISK COUGH GAG INTACT PAIN CONTROLED WITH PCA DILAUDID .12/2/1.2 RATES PAIN [**4-1**].

CV: HR 60 NSR BP 100/40 PULSES EASILY PALPABLE THROUGHOUT. IVF D51/2 NS WITH 20KCL. MAG REPLEATED.

RESP: LUNG SOUNDS CTA ECOURAGE TO COUGH AND DEEP BREATHE INCENTIVE SPIROMETER PERFORMED VOLUMES 1000ML ACHIEVED. SATS 98 2LNC.

GI: NPO ABD SOFT NONTENDER NONDISTENDED HYPOACTIVE BOWEL SOUNDS DENIES NUMBNESS FOR TINGLING -FLATUS.

GU: URINE OUTPUT 50-100CC CLEAR YELLOW URINE HOUR REPLACED FOLEY FOR SLUGGISH OUTPUT WITH + RESPONSE TO NEW CATHETER. LYTES REPLEATED.

SKIN: RIGHT BREAST FLAP INTACT +CIRCULATION +SENSATION BRISK REFILL. INT DOPPLER INTACT WITH +PULSATION. MINIMAL ECCHYMOSIS. TRAM INCISION WELL APPROXIMATED MINIMAL STAINING BENEATH TRANSPARENT DRESSING. JP X 3 PATENT DRAINAING MODERATE AMTS OF SEROSANG FLUID.

ID: TMAX 100.4 WBC 11.2 VANCO

HEME: HCT 33.5 P-BOOTS HEPARIN.

SOCIAL: SUPPORTIVE FRIENDS AND FAMILY SINGLE MOM OLD ADULT CHILDREN MOM [**Name (NI) 4368**].

A: S/P MASTECTOMY BREAST RECONSTRUCTION WITH FREQUENT PULSE CHECKS.

P: MONITOR SURGICAL SITE STATUS AND DRAINS, ADV DIET PROVIDE PAIN CONTROL D/C TO FLOOR.


Sinus rhythm
Long QTc interval
Since previous tracing of [**2183-7-20**], the rate has increased


[** 41**] Physical Exam
Awake and alert. AFOF with great tone and activity. Breath sounds celar and equal on RA without increased respiratory effort. No audible murmur, well perfused with normal pulses and mild jaundice. Abdomen soft and full with active BS, no HSM or masses. Normal GU.


Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   Action:
   Response:
   Plan:


[**Last Name (LF) 2256**],[**First Name3 (LF) 2257**] E.                   [**Doctor First Name 6**] 5S                    [**2119-3-1**]  9:36 AM
 CHEST (PRE-OP PA & LAT)                                         Clip # [**Clip Number (Radiology) 74656**]
 Reason: DIVERTICULITIS
 Admitting Diagnosis: DIVERTICULITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


73 year old woman with diverticulitis


REASON FOR THIS EXAMINATION:


preop
 ______________________________________________________________________________
                                  PFI REPORT
 No evidence of pneumonia or CHF.


[**2160-3-22**] 7:39 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 25364**]
 Reason: Eval intracranial mets
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


52 year old woman with large fungating breast [**Hospital 25365**] distress,
  intubated


REASON FOR THIS EXAMINATION:


Eval intracranial mets
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: ASpf SAT [**2160-3-22**] 9:18 AM
  Multiple hypodensities in the brain are concerning for small metastasis given
  the history of breast cancer. An MRI is recommended for further evaluation. A
  [**Doctor Last Name 1004**]
 WET READ VERSION #1 ASpf SAT [**2160-3-22**] 9:18 AM
  Multiple hypodensities in the brain are concerning for small metastasis given
  the history of breast cancer. An MRI is recommended for further evaluation.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


52-year-old woman with large fungating breast mass and
 respiratory distress.  Evaluate for intracranial mass.


COMPARISON:


None available.


TECHNIQUE:


MDCT images were acquired through the head without contrast.  Bone
 kernel reconstructions and multiplanar reformations were obtained and
 reviewed.


FINDINGS:


No acute hemorrhage, large vascular territory infarct or shift of midline
 structures is present.  There is diffuse punctate areas of hypoattenuation in
 the subcortical and periventricular white matter which could represent small
 metastases.  No osseous metastases are noted.  The visible paranasal sinuses
 and mastoid air cells are well aerated.


IMPRESSION:


Multiple areas of small hypodensities in the brain could represent small
 intracranial metastases.  An MR may be obtained for further evaluation.


Sinus rhythm. Lateral T wave changes are non-specific. Low QRS voltage in the
precordial leads. Compared to the previous tracing of [**2114-10-1**] no significant
change.


Subjective
   Feels well x/ "i want to go back to bed"
   Objective
   Height
   Admit weight
   Daily weight
   Weight change
   BMI
   168 cm
   52 kg
   63.4 kg ([**2189-10-18**] 05:00 AM)
   18.5
   Ideal body weight
   % Ideal body weight
   Adjusted weight
   Usual body weight
   % Usual body weight
   59 kg
   88%
   Diagnosis: Severe aortic stenosis, tricuspid valve regurgitations, s/p
   MVR
   PMH : please see admit note
   Food allergies and intolerances:  NKFA
   Pertinent medications: SS K, SS Mg, SS Ca, reglan, docusate, protonix,
   others noted
   Labs:
   Value
   Date
   Glucose
   111 mg/dL
   [**2189-10-18**] 11:29 AM
   Glucose Finger Stick
   111
   [**2189-10-18**] 08:00 AM
   BUN
   28 mg/dL
   [**2189-10-18**] 02:25 AM
   Creatinine
   1.2 mg/dL
   [**2189-10-18**] 02:25 AM
   Sodium
   130 mEq/L
   [**2189-10-18**] 02:51 AM
   Potassium
   4.2 mEq/L
   [**2189-10-18**] 11:29 AM
   Chloride
   100 mEq/L
   [**2189-10-18**] 02:51 AM
   TCO2
   25 mEq/L
   [**2189-10-18**] 02:25 AM
   PO2 (arterial)
   86.[**Numeric Identifier 253**] mm Hg
   [**2189-10-18**] 02:51 AM
   PCO2 (arterial)
   42 mm Hg
   [**2189-10-18**] 02:51 AM
   pH (arterial)
   7.42 units
   [**2189-10-18**] 02:51 AM
   pH (urine)
   5.0 units
   [**2189-10-16**] 11:26 AM
   CO2 (Calc) arterial
   28 mEq/L
   [**2189-10-18**] 02:51 AM
   Calcium non-ionized
   7.6 mg/dL
   [**2189-10-18**] 02:25 AM
   Phosphorus
   2.7 mg/dL
   [**2189-10-18**] 02:25 AM
   Ionized Calcium
   1.10 mmol/L
   [**2189-10-18**] 12:08 PM
   Magnesium
   2.5 mg/dL
   [**2189-10-18**] 11:29 AM
   WBC
   10.6 K/uL
   [**2189-10-18**] 02:25 AM
   Hgb
   8.6 g/dL
   [**2189-10-18**] 02:25 AM
   Hematocrit
   24.6 %
   [**2189-10-18**] 02:25 AM
   Current diet order / nutrition support: Replete c/ Fiber @ 20mL/hr do
   not advance
   GI: Abd soft/+bs
   Assessment of Nutritional Status
   At risk for malnutrition
   Pt at risk due to: NPO / hypocaloric diet
   Estimated Nutritional Needs
   Calories: 1300-1450 (BEE x  or / 25-28 cal/kg)
   Protein: 64-70 (1.2-1.3 g/kg)
   Fluid: per team
   Estimation of current intake: Inadequate
   Specifics:
   81 yo female, POD #3 for redo-sternotomy, AVR, TVR, removal of pacer
   and placement of LV leads. Pt extubated [**10-16**].  Pt started on TF
s while
   awaiting Swallow eval.  Currently infusing @ 40mL/hr  providing 960
   kcals and 59 gr aa.  Can continue c/ current feed until swallow eval,
   but if pt fails and unable to advance diet, rec change TF to better
   meet estimated needs.  Noted Mg and K repletions.
   Medical Nutrition Therapy Plan - Recommend the Following
   Multivitamin / Mineral supplement: via TF
   Tube feeding recommendations: Change TF to Fibersource HN c/ goal
   50mL/hr (1440 kcals/64 gr aa)
   Check chemistry 10 panel daily
   Start regular insulin sliding scale if serum glucose >150 mg/dL
   Residual checks q4 hr, hold if > 150mL
   Swallow eval- diet per SLP
   Will follow-please page #[**Numeric Identifier 745**] c/ ?'s


[**2114-5-28**] 5:40 PM
 CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST                     Clip # [**Clip Number (Radiology) 67504**]
 Reason: assess for liver abscess size, free air or fluid, and eviden
 Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;FEVER;NEUTROPENIA;R/O TOOTH INFECTION
 Field of view: 42
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


63 year old woman with relapsed AML, neutropenic, with liver abscess s/p liver
  biopsy with significant R pleuritic pain.  Also no BM x 5 days, ? ileus.


REASON FOR THIS EXAMINATION:


assess for liver abscess size, free air or fluid, and evidence of obstruction
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


63-year-old female with relapsed AML, neutropenic, and with liver
 abscess status post biopsy, now with significant right pleuritic pain.  Also,
 with no bowel movement x 5 days.


COMPARISON:


[**2114-5-23**].


TECHNIQUE:


MDCT acquired axial imaging of the abdomen and pelvis after
 administration of oral and intravenous contrast.

 CT ABDOMEN:  Visualized lung bases redemonstrate small right pleural effusion,
 which (despite streak artifact from patient's arm) can be characterized as
 simple low-attenuation fluid. There is adjacent relaxation atelectasis. There
 is a trace amount of left pleural fluid, and left basilar atelectasis.

 Liver contour is unremarkable.  There has been interval decrease in size of
 hypodensity in segment VIII of the liver, which currently measures roughly 19
 x 16 mm, decreased from previous exam when it measured 40 x 36 mm.  No other
 focal liver lesions are identified.  There is no biliary ductal dilatation.
 There is trace ascites around the liver.  The gallbladder, pancreas, spleen,
 adrenal glands, kidneys and ureters are unchanged, again redemonstrating small
 15 mm right adrenal nodule.  Stomach and intra-abdominal loops of bowel are
 unremarkable, without evidence of obstruction.  There is no free
 intraperitoneal air.  There is no enlarged mesenteric or retroperitoneal
 lymphadenopathy.

 CT PELVIS:  Trace free fluid in the pelvis is unchanged.  Urinary bladder is
 partially decompressed, with Foley catheter balloon in place.  Uterus and
 adnexa are unremarkable.  Sigmoid colon and pelvic loops of bowel are
 unremarkable except to note a prominent amount of stool throughout the colon.
 There is no abnormal pelvic or inguinal lymphadenopathy.

 OSSEOUS STRUCTURES:  No suspicious lytic or sclerotic lesions are identified.
 Heterotopic bone formation about the pubic symphysis, and multilevel facet
 degenerative changes and lumbar dextroscoliosis are unchanged.


IMPRESSION:


1.  Interval decrease in size of liver abscess in segment VIII.
 2.  Small right pleural effusion and adjacent relaxation atelectasis.
                                                             (Over)

 [**2114-5-28**] 5:40 PM
 CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST                     Clip # [**Clip Number (Radiology) 67504**]
 Reason: assess for liver abscess size, free air or fluid, and eviden
 Admitting Diagnosis: ACUTE MYELOGENOUS LEUKEMIA;FEVER;NEUTROPENIA;R/O TOOTH INFECTION
 Field of view: 42
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 3.  Unchanged indeterminate right adrenal nodule.

 Above findings were discussed with Dr. [**First Name4 (NamePattern1) 519**] [**Last Name (NamePattern1) 27495**] at approximately
 6:45 p.m. on [**2114-5-28**].


Resp Care Note:

Pt cont trached on mech vent as per Carevue. Lung sounds coarse rhonchi clear after suct for mod th pale yellow sput. MDI given as per order. No changes made overnoc. Cont mech vent support.


FOCUS: STATUS UPDATE
DATA:
PT. AROUSABLE TO VOICE. PERL. FOLLOWING COMMANDS W/R UPPER AND LOWER EXTREMITIES. HAS WIGGLED TOES R FOOT X1 ONLY EARLY AM OTHERWISE NO MOVEMENT WITHOUT STIMULATION. NO MOVEMENT R UE. GARBLED SPEECH. DIFFICULT TO AROUSE THIS PM BUT ONCE STIMULATED OTHER NEURO EXAM UNCHANGED. DR. [**First Name (STitle) **] AWARE. HYPERTENSION MOST OF DAY--VERY DIFFICULT TO CONTROL--NTP, LOPRESSOR, NORVASC AND HYDRALAZINE BEFORE EFFECT. CONTINUES ON LABETOLOL DRIP WHICH IS BEING WEANED. FT INSERTED(GASTRIC) AND TF RESTARTED WITH MINIMAL RESIDUALS. STOOL X2. LASIX STOPPED D/T INCREASED U/O--CONTINUES TO DIURESE WELL WITHOUT DRIP.

PLAN:
WEAN OFF LABETOLOL AND TRANSFER TO FLOOR IN AM.


NICU Triage Note
Infant is a full term male who was brought to NICU at 0900 secondary to temp of 100.4 in NBN this am.  Please see above note for history.
Infant arrived to NICU and was placed on warmer.  VSS.  Temp = 99.4ax. CBC with diff, bld cx, and bili sent.  D/S = 83.  Infant is stable for transfer back to NBN.


[**2102-5-11**] 11:40 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 12838**]
 Reason: R/O PTX
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


67 year old man S/P CABG AND CT REMOVAL


REASON FOR THIS EXAMINATION:


R/O PTX
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Status post CABG and chest tube removal.

 PORTABLE AP VIEW OF THE CHEST:  Comparison [**2102-5-5**].  Patient is status
 post CABG.  Multiple surgical clips overlie the upper abdomen.  A right IJ
 sheath is present extending to the level of the IJ/brachycephalic junction.
 There is obscuration of the left hemidiaphragm, consistent with effusion,
 atelectasis and/or consolidation in this post-CABG patient.


IMPRESSION:


Left basilar consolidation and/or effusion in post-CABG patient.


Subjective
   Patient extubated
   Objective
   Pertinent medications: heparin, famotidine, RISS, octreotide, D51/2 NS
   at 125ml/hr, others noted
   Labs:
   Value
   Date
   Glucose
   141 mg/dL
   [**2160-2-20**] 04:23 AM
   Glucose Finger Stick
   132
   [**2160-2-20**] 06:00 AM
   BUN
   23 mg/dL
   [**2160-2-20**] 04:23 AM
   Creatinine
   0.7 mg/dL
   [**2160-2-20**] 04:23 AM
   Sodium
   134 mEq/L
   [**2160-2-20**] 04:23 AM
   Potassium
   4.4 mEq/L
   [**2160-2-20**] 04:23 AM
   Chloride
   104 mEq/L
   [**2160-2-20**] 04:23 AM
   TCO2
   22 mEq/L
   [**2160-2-20**] 04:23 AM
   Calcium non-ionized
   8.0 mg/dL
   [**2160-2-20**] 04:23 AM
   Phosphorus
   3.5 mg/dL
   [**2160-2-20**] 04:23 AM
   Ionized Calcium
   1.16 mmol/L
   [**2160-2-19**] 07:20 PM
   Magnesium
   1.9 mg/dL
   [**2160-2-20**] 04:23 AM
   Current diet order / nutrition support: NPO
   GI: Abdomen soft with positive bowel sounds
   Assessment of Nutritional Status
   Specifics:
   73 year old male with recent radical cystoprostatectomy and ileal loop
   urinary diversion who presents with SBO, enterococcal UTI, pelvic
   abscess s/p CT guided drainage [**2-15**], now with worsening leukocytosis
   and POD #1 s/p ex-lap with abscess drainage. Patient had been on TPN up
   until going to the OR. Consult received for TPN recommendations.
   Patient was tolerating goal TPN of 2.2L (385g dextrose/120g protein/45g
   lipids) to provide 2239kcal and 120g protein.
   Medical Nutrition Therapy Plan - Recommend the Following
          TPN: 2.2L (385g dextrose/120g protein/45g lipids) with lytes
   (in meq) 265Sodium Chloride, 80Sodium Phosphate, 55Potassium Chloride,
   15Potassium Acetate, 8Magnesium Sulfate, 9Calcium Gluconate
          Will follow closely and adjust TPN daily
   09:40 AM


[**Name8 (MD) 467**] NNP Daily Progress Note

DOL 4, Wt 439gms (up 35gms), HR 130-160, Resp Support SIMV 19/6x18, BP support: on Dopamine 20mcg/kg//min to maintain appropriate MAP, TF 160cc/kg/day, NPO, on PN, D10 and lipids, Urine Output 4cc/kg/hr, tr mec stool, on single phototherapy.

PE: Gen: hypotonic, infant on an open warmer.
Skin: ruddy, mottled, no rashes or lesions, perfusion to all ext at this time.
HEENT: dysmorphic infant consistent with trisomy 21, AFOF, sutures override, extra skin fold at base of neck, upslanting palp fissures, ears posteriorly rotated and low set, nares clear and patent, orally intubated, mouth clear, neck without masses.
Chest: symmetric chest movment with vent breaths, good air entry, breath sounds sl course.
CV: S1S2, no murmur audible at this time, pp palp and =, cap refill <3 sec.
Abd: UVC in place, abd soft, BS hypoactive but present, NT/ND.
GU: nl female, patent anus.


Labs:VBG 7.24/39/133/18/-10, D-stick 143-150, lytes 143/4.9/113/19, bili 5.6/0.3/5.3.

Meds: Dopamine, Ampicillin, Gentamicin.

IMP: [**Known lastname 115**] is a 24 [**3-30**] week infant who is now 25+ week corrected gestational age. She remains to have a labile course here in the NICU. She is currently receiving resp support of mechanical ventilation to treat resp distress/surfactant deficiency, Dopamine for hypotension, PRBC x 2 to increase intravascular volume and BP, NaHCO3(2meq/kg) for persistent met acidosis, Indomethacin for treatment of a PDA, phototherapy for hyperbilirubinemia and a 7 day course of antibiotics for presumed sepsis at birth. Her HUS was normal yesterday and her [**Month/Day (4) **] were updated on her condition at a family meeting. The UAC had to be removed last evening for recurring cyanosis of a leg.

Plan: CV: Continue to monitor BP closely and wean Dopamine as tolerated. A UAC was replaced this AM for closer monitoring  but cyanosis was apparent bilat below the level of the umb shortly after insertion and it was subsequently removed.
RESP: CXR this AM revealed bilat PIE, infant was then placed on the HFOV in an attempt to decrease volutrauma.
FEN: Maintain TF of 160cc/kg/day, and increase PN to 100cc/kg/day, monitor D-sticks and lytes Q8h. UVC was replaced this am and remains in good position.
GI: Increase to double phototherapy and repeat bili with next set of lytes.
Heme: no issues currently. Will consider further PRBC transfusions for BP management.
ID: continue on Amp and Gent, today is day 4 of 7.
Neuro: Will recheck HUS next week or sooner if infant's condition deteriorates further. Fentanyl was given for agitation related to procedures.
Social: [**Month/Day (4) **] have been updated on infants condition today.


NPN


#1Resp Lungs clear. RR 40-60. No A+B's noted at rest. Does
drift in O2 sat with bottle. Resolves quickly when rest
given. Soft murmur audible  HR 140-160.Hct 25 color
[** 316**]/mottled. A-Unchanged no signs of compromise P- Continue
to follow.
#2F/N O- Wt up 20gms 1860. [**Known lastname 936**] bottled x2 Nuk nipple
used. Continues on BM 28cal at 150cc/kg Infant voiding well
Still passing soft /liquidy stool. Buttock remain reddened.
Criticaid applied. Abdomen benign. A- Did better w/ NUK
still has occassional desats. P- Follow wts. Encourage
breast/bottle.
#3Dev. No change. #4Family Mom called x1 and updated.
#7hernia/orchiopexy No change.
#8Sepsis Remains on Antibiotics. Day 6.


Respiratory Care
Pt remains on SIMV 16/5 x 16 .21FiO2 w/sats > 90%  BBS slt coarse and diminished.  Sx'd for moderate cloudy white secretions.  Comfortable RR 40-50s w/good Vt and spont efforts.  Cont on caffeine.  No spells. No vent changes.  Plan is to reevaluate at the end of week for extubation.  Continue minimal settings and CXR prior to extubation to reassess ptx/pneumomediastinum.  Will continue to follow.


11a-11pm  update
neuro: pt [**Last Name (LF) **], [**First Name3 (LF) 55**] and able to follow commands. PERRL. pt very stiff -> ROM done

CV: pt remains NSR, no ectopy noted. HR 70-90's. BP 100-140's/60-70's. MAP 70-90's. pt started on lopressor IV q6h today - tolerated well. pp by doppler. plt 38 this am. HIT negative. pt started on lovenox today -> team aware of plts in the 30's and still want lovenox given.

resp: LS clear with dim bases bil. pt suctioned for thin white sputum. pt placed on 50% trach collar this morning -> tolerating well. o2 sats 96-100%. rr 20-30's. pleural drain (on upper back) to bulb suction, draining serousainginous drainage

gi/gu: abd opened -> covered with vac dressing - drianing serous fluid. + hypoactive bs. G [**First Name3 (LF) **] to gravity draining billious fluid. pt recieving Impact [**First Name3 (LF) **] feeding at 60 cc/hr (goal) via J [**First Name3 (LF) **]. minimal residual. pt had 1 lg  brown loose stool -> mushroom catheter fell out. mushroom catheter replaced. Creatinine 1.6 this am. foley remains [**First Name3 (LF) 235**] and draining clear yellow urine. UO adequate. pt with pancreatic drain to LWS -> drain flushed with 30 cc NS Q2h.

endo: elvated bs treated with ss reg insulin as ordered.

skin: abd open -> covered with Vac. coccyx,lower back, buttocks and upper thighs covered with abbrasions draining small serousanginous fluid. 2 abbrasions noted on right wrist. right foot with 1 abbrasion. left lower leg with abbrasion, left heal with pressure ulcer. right grion with open area -> [**First Name3 (LF) 2169**] bed pink -> draining small amount of serousanginous fluid. under left breast -> multiple abbrssions. left chest wall covered with DSD. all skin care/dressings done per [**First Name3 (LF) 2169**]/skin care nurses recommendations

id: wbc's 16.2. pt afebrile. continues on tigecycline,meropenum and fluconazole.

social: no calls today. no visits today

plan: antibiotics, skin care, pulm toliet, monitor plt's, monitor hemodynamics, continue supportive care


[**2186-10-13**] 4:58 PM
 US ABD LIMIT, SINGLE ORGAN                                      Clip # [**Clip Number (Radiology) 22551**]
 Reason: rule out splenic infarct
 Admitting Diagnosis: CROHN'S FLARE
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


51 year old man with presumptive Crohn's flare, ?splenic infarct on abdominal
  CT


REASON FOR THIS EXAMINATION:


rule out splenic infarct
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


51-year-old male with Crohn's, splenic infarct on CT.


COMPARISON:


CT from [**2186-10-12**].

 LEFT UPPER QUADRANT ULTRASOUND:  The spleen measures 12.4 cm.  In the anterior
 portion, there is a vague heterogeneously hypoechoic area, corresponding to
 known infarct.  This appears similar in size, although comparison is difficult
 across imaging modalities.  Vascular supply was not well evaluated with color
 and power Doppler techniques, due to patient body habitus.  An echogenic focus
 with dirty shadowing at the splenic hilum corresponds to known loculated gas
 seen on CT, suggestive of persistent fistulous tract with the splenic flexure
 of the colon.


IMPRESSION:


1.  Vague hypodensity within anterior spleen, consistent with known infarct.
 Vascular supply not well evaluated due to patient body habitus.
 2.  Focal echogenicity in splenic hilum corresponds to known locule of gas
 from presumed persistent fistulous tract with splenic flexure.


[**2192-7-14**] 1:30 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 60741**]
 Reason: r/o ptx
 Admitting Diagnosis: CORONARY ARTERY DISEASE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


70 year old man with cabgx2 w/ptx s/p ct placement


REASON FOR THIS EXAMINATION:


r/o ptx
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST ON [**2192-7-14**] AT 13:40


INDICATION:


Check for PTX after chest tube placement.


COMPARISON:


[**2192-7-13**] at 15:22.


FINDINGS:


Since the prior exam, the patient has been extubated and the Swan-Ganz
 catheter has been removed.  A right introducer sheath remains.  Two chest
 tubes are visualized, and a mediastinal drain is in place.

 There is no PTX.  No new consolidations and no evidence for declining fluid
 status.


IMPRESSION:


Line and tube removal without PTX, and no change in
 cardiopulmonary status.


Chief Complaint: EtOH withdrawal
   I saw and examined the patient, and was physically present with the ICU
   Resident for key portions of the services provided.  I agree with his /
   her note above, including assessment and plan.
   HPI:
   37 y/o M w/longstanding hx of EtOH abuse s/p multiple ED/ICU
   admissions, s/p section 35 most frequently last month, who was brought
   into the ED last night after he was found by the police.  EtOH 434 at
   10 AM.  Admitted to medicine floor.  Required 50 mg valium in the first
   40 minutes on the floor, so transferred to the MICU.
   24 Hour Events:
   - overnight, has received 80 mg po valium
   - asked for a gun in order to kill himself, so has a sitter and is on
   suicide precautions
   - This morning states that he wants more valium.
   Allergies:
   Penicillins
   Unknown;
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2181-10-24**] 12:00 AM
   Other medications:
   folate, thiamine, multivitamin, lamivudine, valium 20 mg po prn (has
   been getting this approx q2h)
   Changes to medical and family


history:


PMH, SH, FH and ROS are unchanged from Admission except where noted
   above and below
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Pain location: c/o pain in whole body
   Flowsheet Data as of  [**2181-10-24**] 10:15 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37
C (98.6
   Tcurrent: 36.6
C (97.8
   HR: 70 (68 - 123) bpm
   BP: 123/81(91) {93/61(70) - 123/81(91)} mmHg
   RR: 15 (10 - 16) insp/min
   SpO2: 97%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 68 Inch
             Total In:
                                                                    120 mL
                                                                  1,226 mL
   PO:
                                                                    120 mL
                                                                    120 mL
   TF:
   IVF:
   1,106 mL
   Blood products:
   Total out:
                                                                      0 mL
                                                                  1,750 mL
   Urine:
   1,750 mL
   NG:
   Stool:


71yo male w/ PMH DM(metformin), HTN, COPD & OSA who presented with
   worsening dyspnea over the past week w/ minimal exertion, relieved with
   rest.  Denies chest discomfort,  palpitation, dizziness, presyncope or
   syncope.  Presentes to  PCP [**8-19**]. ECG showing type II Second Degree AV
   block w/ HR in 30s.  Tx  to [**Hospital3 7490**] >>[**Hospital1 1**]. Seen by


Admission Date:  [**2142-10-4**]              Discharge Date:   [**2142-10-12**]

Date of Birth:  [**2077-5-18**]             Sex:   F

Service: SURGERY

Allergies:
Levaquin / Erythromycin Base

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Trauma:  fall


Major Surgical or Invasive


Procedure:


Thoracic epidural catheter placed [**10-4**], d/c [**10-7**]
Chest tube placed [**10-8**], chest tube d/c [**10-12**]


History of Present Illness:
HPI: 65F, s/p fall from standing in her basement at home, struck
radiator.  Presented to OSH, had head, C-spine, torso CT scans.
Found left-sided multiple rib fractures with flail chest, less
than 5% pneumothorax, small hemothorax. EtOH level 200 at
outside hospital. Received fentanyl 50 mcg by EMS in field, and
then morphine 4 mg IV x2 and Benedryl 25 @ OSH. Arrived at [**Hospital1 18**]
somnolent, with small pupils, GCS [**6-1**], received Narcan with good
effect.  In ED, eFAST re-demonstrated L PTX anteriorly.  Pt c/o
severe pain in L chest.

INJURIES:
- fractures left ribs [**4-1**]
- small L PTX - detected on FAST & CT, not visible on CXR
- small L hemothorax


Past Medical


History:


PMH: hypothyroid, GERD, depression


Social


History:


positive etoh

Family


History:


non-contributory

Physical


Exam:


PHYSICAL


EXAMINATION:


upon admission: [**2142-10-4**]

HR: 90 BP: 129/99 Resp: 12 O(2)Sat: 94

Constitutional: On arrival somnolent, [**Name (NI) 91248**]
respirations, not following
HEENT: Pupils and
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft. Distended
Extr/Back: Moving all extremities
Neuro: Moaning to pain


Pertinent Results:
[**2142-10-11**] 05:10AM BLOOD WBC-7.8 RBC-3.25* Hgb-10.5* Hct-30.5*
MCV-94 MCH-32.2* MCHC-34.4 RDW-13.6 Plt Ct-398
[**2142-10-10**] 05:15AM BLOOD WBC-7.2 RBC-3.03* Hgb-9.8* Hct-28.8*
MCV-95 MCH-32.3* MCHC-34.0 RDW-13.6 Plt Ct-289
[**2142-10-9**] 05:50PM BLOOD Hct-31.4*
[**2142-10-4**] 05:26AM BLOOD WBC-17.6* RBC-4.53 Hgb-14.7 Hct-44.9
MCV-99* MCH-32.4* MCHC-32.7 RDW-12.4 Plt Ct-290
[**2142-10-4**] 05:26AM BLOOD Neuts-86.9* Lymphs-10.5* Monos-1.6*
Eos-0.7 Baso-0.4
[**2142-10-11**] 05:10AM BLOOD Plt Ct-398
[**2142-10-10**] 05:15AM BLOOD Plt Ct-289
[**2142-10-10**] 05:15AM BLOOD Glucose-104* UreaN-10 Creat-0.5 Na-136
K-4.1 Cl-98 HCO3-31 AnGap-11
[**2142-10-9**] 03:47AM BLOOD Glucose-102* UreaN-9 Creat-0.5 Na-136
K-4.0 Cl-97 HCO3-32 AnGap-11
[**2142-10-4**] 05:26AM BLOOD Glucose-186* UreaN-14 Creat-0.8 Na-138
K-5.4* Cl-103 HCO3-21* AnGap-19
[**2142-10-10**] 05:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
[**2142-10-9**] 03:47AM BLOOD Calcium-8.5 Phos-2.7# Mg-2.0
[**2142-10-4**] 05:26AM BLOOD ASA-NEG Ethanol-98* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

[**2142-10-4**]:  chest x-ray:


IMPRESSION:


1. Minimal bibasilar atelectasis with possible left retrocardiac

consolidation.
2. Possible small left pleural effusion.
3. No pneumothorax.

[**2142-10-4**]:  chest x-ray:

 There is no definitive pneumothorax. There are persistent low
lung volumes.
Cardiomegaly is stable. There is small left pleural effusion.
Bibasilar
atelectases have increased on the right. Left rib fractures are
again noted.
Opacity in the left lower lobe as mentioned before could be
consolidation,
atelectasis and/or contusion.

[**2142-10-6**]:  chest x-ray:

There is a cardiomegaly which is stable. There is some
atelectasis at the
lung bases. There is an element of pulmonary edema. Multiple
displaced rib
fractures are seen on the left side which are stable. In the
left upper lobe, there is a prominent edge within the left upper
lobe which is equivocal for pneumothorax and is likely a skin
fold. If there is high clinical concern, this could be further
evaluated with repeat radiographs with the patient in a
different position.

[**2142-10-7**]:  chest x-ray:

There are again seen multiple displaced rib fractures on the
left side. The previously mentioned edge which was suspicious
for pneumothorax is no longer seen. No definite pneumothoraces
are identified. There is atelectasis and
bilateral pleural effusions at the lung bases. The heart size is
upper limits of normal.

[**2142-10-7**]: x-ray of the abdomen:


IMPRESSION:


1. Nonspecific bowel gas pattern without evidence of
obstruction, ileus, or free air.
2. Multiple unchanged left-sided rib fractures.

[**2142-10-8**]:  chest x-ray:


IMPRESSION:


Large right pleural effusion increased since [**2142-10-7**] with
mediastinal
shift to the right side.

[**2142-10-9**]:  chest x-ray:

 Moderate left pleural effusion has increased in size despite
the left pleural drain, whose most proximal side port is in the
plane of the intercostal space or extrathoracic. There could
also be fluid accumulating in the submuscular soft tissues.
Right lung volume has improved and vascular congestion in that
lung has decreased. Heart is moderately enlarged, but smaller
today. No right pneumothorax.

[**2142-10-11**]:  chest x-ray:


FINDINGS:


A left chest tube remains in place. The side port
overlies the
lateral left rib cage, and is difficult to determine from this
single view
whether the side port is intrapleural or extrapleural. Small
left apical
pneumothorax has minimally increased in size. Moderate loculated
left pleural effusion is slightly smaller, and continues to be
accompanied by adjacent atelectasis in the left mid and lower
lung regions. On the right, a small pleural effusion is
unchanged, but adjacent atelectasis has improved.
Numerous contiguous left segmental rib fractures are again
demonstrated
concerning for flail chest.

[**2142-10-11**]:  cat scan of the chest:


1. Multiple displaced and overriding left rib fractures with
partially
hemorrhagic, moderate left pleural fluid associated with
atelectasis of the adjacent lung. To determine if any of its
component is locuated, left lateral decubitus radiograph be
performed.

2. Small left pneumothorax.

3. Multifocal, nondependent ground-glass opacities,
predominantly in the
right lung, diagnosis unclear.

[**2142-10-12**]:  chest x-ray ( post chest tube removal):












Brief Hospital Course:
65 year old female admitted to the acute care service after a
fall in which she sustained left sided rib fractures.  Upon
admission, she was made NPO, given intravenous fluids, and the
Pain service was consulted for placement of an epidural catheter
for analgesic control of rib pain.

On HD #1,  she was admitted to the trauma intensive care unit
for placement of a thoracic epidural catheter for pain control.
A foley catheter was also placed.  Because of her history of
ETOH, she was placed on a CIWA scale. Her rib pain was
controlled but she continued to have episodes of desaturation.
She was encouraged to use the incentive spirometer and her
oxygen saturations improved.  She was transferred to the
surgical floor on HD #3.

She was transferred to the trauma intensive care unit on HD #4
with shortness of breath. A chest x-ray did show a fluid
collection and a chest tube was placed for a hemothorax of
700cc.  Her respiratory status improved with placement of the
chest tube.  During this time, she also had episodes of
confusion which were thought to be related to her narcotic
analgesia.  Her mental status cleared once her narcotics were
discontinued. She did require 2 units of PRBC for a hematocrit
of 22.  After the transfusion, her hematorcrit increased to 30.


She was transferred to the surgical floor on HD #5.  At this
time, her chest tube was placed to water seal and she maintained
adequate oxygenation.  She was encouraged to use the incentive
spirometer.   She was evaluated by physical therapy and she
demonstrated functional mobility necessary for discharge home.

Her chest tube was discontinued on HD # 9 and she had a chest
x-ray done after removal. Her vital signs are stable and she is
afebrile.  She is tolertating a regular diet.  She has been
ambulating without any shortness of breath.

The social worker has been in to visit and provided with options
for additional counselling upon discharge. Home safety issues
were addressed and patient reportedly feels comfortable with her
spouse.

She is preparing for discharge to her daughter's home.  She will
follow up with the acute care service in 3 weeks.  She has been
instructed that she is not allowed to fly for 1 month.

Of note:  your chest x-ray did show multifocal, nondependent
ground-glass opacities, predominantly in the right lung.  Your
primary care provider [**Name9 (PRE) **] [**Name9 (PRE) 702**] on this.  Acute care
clinic called on [**10-16**] and informed that patient will need a
copy of discharge summary to bring to her primary care provider.


Medications on Admission:
MEDS: Lexapro 40', Synthroid 100', Prilosec 40"


Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrrhea.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. escitalopram 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) inh Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Trauma:  fall

left [**5-2**] rib fractures
left pneumothorax
left hemothorax


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital after you fell onto a radiator
and sustained left sided rib fractures. You were admitted to the
intensive care unit where you had a special catheter placed in
your back to help control your rib pain. You were transferred
out of the intensive care unit to the surgical floor.  You
developed a decreased blood count and you were found to have a
collection of blood in your lung.  You returned to the intensive
care unit for placment of a chest tube.  Once your vital signs
and your blood count stabilized, you returned to the surgical
floor.  You have made great progress in your recovery.  You had
the chest tube removed and you are preparing for discharge home
with the following instructions:

*  Your injury caused rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.

*  You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.

*  Pneumonia is a complication of rib fractures.  In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake.  This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.

*  You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.

*  Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.

*  Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.

*  Do NOT smoke

*  If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.

*  Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).


Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please call the Acute Care Surgery clinic to make a follow up
appointment to be seen in 3 weeks. Please call on Monday to make
this appointment.


YOu will also need to follow up with your primary care provider
once you arrive home.  Please provide them with your discharge
summary.



Completed by:[**2142-10-16**]


[**2129-1-26**] 8:11 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 23137**]
 Reason: s/p chest tube pull, please eval for pneumothorax
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


70 year old man with


REASON FOR THIS EXAMINATION:


s/p chest tube pull
  please eval for pneumothorax
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST [**2129-1-26**].


INDICATION:


Chest tube removal.  Rule out pneumothorax.

 PORTABLE AP UPRIGHT CHEST:  Compared to the chest radiograph of [**1-19**],
 there has been interval placement of a right IJ Swan-Ganz catheter which
 terminates in the proximal right main pulmonary artery.  The patient is status
 post median sternotomy and CABG.  Incidental note is made of an azygos lobe
 fissure.  There is no evidence of pneumothorax.  There is a small left pleural
 effusion and left basilar atelectasis.


IMPRESSION:


Expected postoperative appearance for median sternotomy and CABG.
 No evidence of pneumothorax.


[**2129-4-29**] 5:09 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 93406**]
 Reason: eval for infiltrate
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


70 year old woman with fever, hypoxia, altered mental status.


REASON FOR THIS EXAMINATION:


eval for infiltrate
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


70 year old woman with fever and hypoxia.

 There are no studies for comparison.

 CHEST, SINGLE VIEW:  There is mild cardiac enlargement.  The mediastinal and
 hilar contours are unremarkable.  There are low lung volumes with elevation of
 the right hemidiaphragm.  Patchy opacities are noted predominantly at the
 right lung base.  The soft-tissue and osseous structures are unremarkable.
 There are no pleural effusions.


IMPRESSION:


1) Cardiomegaly without evidence of failure.

 2) Patchy opacity at the right lung base likely represents atelectasis in the
 setting of right hemidiaphragm elevation.  However, a developing
 pneumonia/aspiration cannot be excluded in the appropriate clinical context.


[**Age over 90 **] yo woman admitted from nursing home with aspiration PNA and UTI.
   Placed on contact precautions today as micro data growing back multi
   antibiotic resistant bacteria. Pt O2 dependent, mental status improving
   somewhat, niece describes Aunt (patient) as being able to hold
   conversation and easily redirected from dementia. Does report as
   contantly talking and does like to converse with other residents. Is
   usually bed or chair bound and requires assist to eat at home. Today
   patient failed bedside swallow evaluation. Remains NPO. DNR/DNI. MDs to
   discuss nutrition status with niece. Niece will probably refuse any
   feeding tube.
   Impaired Skin Integrity
   Assessment:
   Deep tissue injury on coccyx irregular in shape, approx 3cm in length
   and 1cm wide. Area not open, cleansed w/aloe vesta foam and aloe vesta
   cream applied. Pt w/perineal fungal rash, criticaid antifungal applied
   after  cleansing. Left heel blister remains intact, approx 2cm in
   diameter. Waffle boot intact. OOB to chair w/waffle cushion for 2
   hours. Patient turned and repositioned at least q2hours.
   Action:
   Unit based specialists assisted w/evaluation and plan of care for skin
   impairments.
   Response:
   Skin integrity without further apparent demise.
   Plan:
   Turn and position at least q2hours. OOB to chair w/waffle cushion for
   not more than 2hours at a time. Waffle boot to left leg, heels off of
   bed. Continue w/first step air mattress. Deep tissue injury: cleanse
   w/foam cleaner and apply aloe vesta cream. Criticaid clear antifungal
   ointment to perinueum every third cleansing.
   Altered mental status (not Delirium)
   Assessment:
   Pt talking incessantly for most of the day. Appears happy and without
   pain. Speech garbled despite frequent mouth care, membranes appear dry.
   Niece called and stated that baseline is usually albe to converse when
   utilizing hearing assistive device (does not have hearing aid).
   Action:
   Spoke loudly into right ear, reorient as able.
   Response:
   Occasionally able to hear in right ear w/loud speech.
   Plan:
   Move slowly, speak loudly and reorient as able.
   Pneumonia, bacterial, hospital acquired (non-VAP)
   Assessment:
   Face tent 35-40%, patient usually takes off O2 and desats to 89%, pt
   w/moist productive cough, unable to obtain specimen for sample. Crackes
   bibasilar this morning as well as i/e wheezes, lasix 10mg IV w/fair
   response.
   Action:
   Pt pulling off O2, NC placed and titrate up to 6L nc to maintain O2 sat
   94%.
   Response:
   RA O2 sat 89%
   Plan:
   Cont supplemental O2, wean as tolerated. OOB as tolerated (slide board
   to stretcher chair on waffle cushion).


Neonatology Attending Note
Day 69, PMA 38 4

RA. RR40-60s. No A&Bs. Soft murmur. HR 140-160s. Wt up 5 to 2505. Min 140. TFI: 170. BM24 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 298**] powder. [**Last Name (NamePattern4) **] well. Nl voiding and [**Last Name (NamePattern4) **]. Vit E and Fe. Open crib.

A/P:
Growing former perterm infant awaiting complete observation period for resolution of apnea of prematurity. Eye exam tomorrow. Potential d/c if no new events Tuesday. d/c Vit E. Begin MVI.


[**2129-1-19**] 7:00 PM
 MRA KIDNEY W&W/O CONTRAST                                       Clip # [**Clip Number (Radiology) 1767**]
 Reason: r/o renal artery stenosis
 Admitting Diagnosis: HYPERTENSIVE EMERGENCY;TELEMETRY
  Contrast: MAGNEVIST Amt: 20
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


35 year old man with hypertensive urgency


REASON FOR THIS EXAMINATION:


r/o renal artery stenosis
 No contraindications for IV contrast
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): [**First Name9 (NamePattern2) 1768**] [**Doctor First Name 141**] [**2129-1-20**] 12:00 PM


INDICATION:


35-year-old with hypertensive urgency.

  COMPARISONS:  Renal ultrasound of [**2129-1-18**].


TECHNIQUE:


Multiplanar T1- and T2-weighted images through the abdomen per
  renal MRA protocol with dynamic 3D sequences performed before, during and
  after the uneventful administration of 0.1 mmol/kg of gadolinium-DTPA.

  No evidence of renal artery stenosis.  The main renal arteries are widely
  patent, and there accessory renal arteries on both sides.  Normal and
  symmetric renal size.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


hypertensive urgency.


COMPARISON:


Renal US of [**2129-1-18**].


TECHNIQUE:


Multiplanar images through the abdomen with dynamic 3D sequences
 before, during, and after the uneventful administration of 0.1mmol/kg of
 gadolinium-DTPA.

 MRI RENAL


FINDINGS:


The kidneys are normal in size and symmetric, the right
 10.6 cm and the left 10.3 cm.  The kidneys enhance normally and demonstrate
 normal thickness of the cortex.  The main renal arteries are widely patent
 bilaterally, with note made of a small accessory renal artery on both sides;
 on the right to the upper pole, on the left to the lower pole.  No concerning
 renal lesions are appreciated.

 The imaged portions of the liver, spleen, pancreas and intra-abdominal bowel
 are within normal limits.  The adrenal glands are normal appearing.  The
 visualized osseous structures are normal.

 2D/3D and subtraction sequences provide multiple perspectives for the above
 findings.


IMPRESSION:


Normal renal MRA.  No evidence of renal artery stenosis.

                                                             (Over)

 [**2129-1-19**] 7:00 PM
 MRA KIDNEY W&W/O CONTRAST                                       Clip # [**Clip Number (Radiology) 1767**]
 Reason: r/o renal artery stenosis
 Admitting Diagnosis: HYPERTENSIVE EMERGENCY;TELEMETRY
  Contrast: MAGNEVIST Amt: 20
 ______________________________________________________________________________


FINAL REPORT


(Cont)


Sinus rhythm.  Normal tracing.  Compared to the previous tracing of [**2111-7-13**]
the rate has slowed.  Otherwise, no diagnostic interim change.


[**2135-4-12**] 5:48 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 80407**]
 Reason: eval for interval change
 Admitting Diagnosis: RIGHT PNEUMOTHORAX
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41yo M s/p R VATS/blebectomy for spontaneous PTX, with CTx2 to suction, hypoxic


REASON FOR THIS EXAMINATION:


eval for interval change
 ______________________________________________________________________________


FINAL REPORT


AP CHEST, 5:48 A.M., [**4-12**].


HISTORY:


VATS blebectomy.


IMPRESSION:


AP chest compared to [**4-8**] through 14.

 Unchanged since [**4-10**] is loss of volume in the right lung, apical
 paramediastinal hematoma and small pleural fluid loculations.  Two right
 pleural tubes are unchanged in their respective positions.  Mild cardiomegaly,
 stable.  Left lung clear.  No appreciable pneumothorax.


.H/O anxiety
   Assessment:
   Pt very anxious about pain/turning at beginning of shift
   Action:
   Ativan was given on prior shift, reassurance provided
   Response:
   Pt less anxious now
   Plan:
   Continue ativan as prn, encourage reassurance and poc
   Coronary artery bypass graft (CABG)
   Assessment:
   Pt is hemodynamically stable requiring
   Action:
   Response:
   Plan:
   .H/O pain control (acute pain, chronic pain)
   Assessment:
   Action:
   Response:
   Plan:


[**Last Name (LF) 10111**],[**First Name3 (LF) **] E.              [**Doctor First Name 108**] FA11                  [**2133-3-2**] 11:39 AM
 CT ABD & PELVIS WITH CONTRAST                                   Clip # [**Clip Number (Radiology) 58505**]
 Reason: 70 year old man with hydrocephalus and VPS replacement, plea
 Admitting Diagnosis: HYDROCEPHALUS
  Contrast: OPTIRAY Amt:
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


70 year old man with hydrocephalus and VPS replacement, please evaluate for
  interval changes


REASON FOR THIS EXAMINATION:


70 year old man with hydrocephalus and VPS replacement, please evaluate for
  interval changes
 No contraindications for IV contrast
 ______________________________________________________________________________
                                  PFI REPORT
 Dilated small bowel up to 4.7 cm with decompressed terminal ileum with
 possible adhesions concerning for small-bowel obstruction.  Wall edema in the
 distal small bowel could reflect obstruction, however, can also be seen in
 ileus, ischemia and reactive to procedure or intraperitoneal fluid.


Neonatology Attending

DOL 25 PMA 39 4/7 weeks

Stable on RA.

Soft murmur.  BP 73/43 mean 53.

NPO on 140 ml/kg PN15/IL.  Voiding.  No stool.  KUB yesterday was normal.  Wt 2900 grams (up 65).

Completing 14 days antibiotics today.

Family in and up to date.

A:  Stable.  Treatment course for NEC complete.  Ready to start feeds.

P:  Monitor
    D/C antibiotics
    Start feeds
    Monitor GI status


#1Resp
baby cont on [**Name (NI) 5087**] 6cm with FIO2 between 35-40%. RR 50-70's
with subcostal retractions. Lungs clear. Baby cont on
diuril, KCl, zantac, and reglan.
A. Unchanged
P. cont to monitor. Await ORL. ? [**Known lastname 5076**] next week.
#2FEN
Wt 3.895 which is up 55g. Baby cont to receive 140cc/kg of
E24. Abd soft, active bowel sounds. voiding. Large soft
stool at [**2103**] anthen a large liquid stool which was guiac
neg at 2400. Bath given. All feed received by gavage.
A. Tol feeds
P. cont to monitor weight gain weight.
#3Dev
Axilaary temp 97.7, but baby [**Name (NI) 5088**]. [**Name2 (NI) 13**] 96.6 R. Awake most
of the shift. Up in swing. Fussy at times. Sucks on a
pacifier.


SICU
   HPI:
   73F with panc mass by imaging, now s/p classical Whipple [**7-16**]. admitted
   to SICU with hypoxic resp distress, likely secondary to anastomatic
   leak with ?sepsis
   Chief complaint:
   respiratory failure
   PMHx:
   HTN, hlipid, tics&polyps, breast ca [**2158**] s/p L mast, osteopenia, panc
   cyst, esophagitis, hypothyroidism, colitis s/p partial colectomy,
   arthritis, urin incont
   Current medications:
   1. 2. Acetaminophen 3. Bisacodyl 4. Calcium Gluconate 5. Chlorhexidine
   Gluconate 0.12% Oral Rinse
   6. Ciprofloxacin 7. HYDROmorphone (Dilaudid) 8. Heparin 9. Heparin
   Flush (10 units/ml) 10. HydrALAzine
   11. 12. Insulin 13. Levothyroxine Sodium 14. Metoprolol Tartrate 15.
   Metoclopramide 16. Midazolam
   17. Midazolam 18. Miconazole Powder 2% 19. Octreotide Acetate 20.
   Pantoprazole 21. Phenaseptic Throat Spray
   22. Potassium Chloride 23. Sodium Chloride 0.9% Flush 24. Vancomycin
   24 Hour Events:
   Patient with episode of destaturation overnight, due to mucus plugging.
   Responded to suction down trach and lavage. Patient maintained on
   increased pressure support (5-->15) after episode of desat to maintain
   O2 Sat
   Allergies:
   Pravachol (Oral) (Pravastatin Sodium)
   Rash;
   Lisinopril
   Rash;
   Last dose of Antibiotics:
   Vancomycin - [**2188-7-30**] 08:59 PM
   Ciprofloxacin - [**2188-7-30**] 10:31 PM
   Infusions:
   Midazolam (Versed) - 2 mg/hour
   Other ICU medications:
   Hydralazine - [**2188-7-30**] 06:30 PM
   Hydromorphone (Dilaudid) - [**2188-7-30**] 07:01 PM
   Pantoprazole (Protonix) - [**2188-7-30**] 08:59 PM
   Metoprolol - [**2188-7-31**] 12:31 AM
   Other medications:
   Flowsheet Data as of  [**2188-7-31**] 03:34 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**91**] a.m.
   Tmax: 37.2
C (98.9
   T current: 36.8
C (98.3
   HR: 73 (54 - 100) bpm
   BP: 156/58(81) {105/33(49) - 187/82(104)} mmHg
   RR: 18 (14 - 29) insp/min
   SPO2: 98%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 100.7 kg (admission): 86.3 kg
   Height: 67 Inch
           Total In:
                                                                  3,407 mL
                                                                    374 mL
   PO:
           Tube feeding:
                                                                     24 mL
                                                                     93 mL
   IV Fluid:
                                                                    919 mL
                                                                     37 mL
   Blood products:
                                                                     50 mL
                                                                     50 mL
   Total out:
                                                                  5,677 mL
                                                                    235 mL
   Urine:
                                                                  4,187 mL
                                                                    235 mL
   NG:
                                                                  1,475 mL
   Stool:


Nursing Progress Note 1900-0700 hours:
** Full code

** allergy: codeine, benadryl, clonidine

** access: 2 right arm piv's

Pls see admit note and FHP for data

NEURO: A & O x3, appropriately anxious and scared.  Valium prn (takes at home) and trazadone given for sleep with minimal effect.

CV: NSR-ST with HR 65-82.  No ectopy.  SBP 104-168/55-79.  Hct stable.  Denies any CP or related symptoms.

RESP: rr normal. Lungs clear.  Sats 93-97% on RA.

GI/GU: abd soft, obese, softly distended, + BS. NPO since midnight for OR. Foley placed without event-draining clear, yellow urine and specs sent to lab.

ID: afebrile.

SKIN: No issue. slightly reddened bottom.  OR SCRUB with chlorhexidine done.

SOCIAL: supportive spouse and family-numbers on board, OR paperwork.  Catholic priest came and blessed pt per her request.

PLAN: -awaits transport to OR for 3 or 4 vessel CABG-scheduled for 630a
      -cont to offer emotional support
      -cont med regimen and icu supportive care.


Name:  [**Known lastname **] [**Known lastname 12470**],[**Known firstname 194**] B         Unit No:   [**Numeric Identifier 12471**]

Admission Date:  [**2179-12-14**]              Discharge Date:   [**2179-12-31**]

Date of Birth:  [**2136-1-30**]             Sex:   F

Service: SURGERY

Allergies:
ATRIPLA / Morphine / Percocet

Attending:[**First Name3 (LF) 2800**]
Addendum:
Cyclosporin discontinued

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] [**Hospital 12472**] Hospice House

                             [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]

Completed by:[**2179-12-31**]


[**2148-1-18**] 12:59 PM
 FEMUR (AP & LAT) BILAT; ANKLE (AP, MORTISE & LAT) RIGHT         Clip # [**Clip Number (Radiology) 101214**]
 Reason: s/p ORIF bilateral femurs
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


25 year old man with


REASON FOR THIS EXAMINATION:


s/p ORIF bilateral femurs
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Status post ORIF of bilateral femoral fractures.


COMPARISON:


CT right lower extremity [**2147-12-10**] and right ankle radiographs
 [**2147-12-22**].

 RIGHT FEMUR, FOUR VIEWS:  Comminuted fracture of the proximal femoral
 diaphysis is transfixed by an intramedullary rod with a single proximal gamma
 nail and two distal interlocking screws.  A butterfly fracture fragment
 remains slightly medially displaced. There has been interval development of
 bridging callus formation. The fracture lines remain visible. No evidence of
 hardware loosening or failure is present. Alignment is unchanged.

 RIGHT ANKLE, THREE VIEWS:  Comminuted fracture of the distal tibia and fibula
 are transfixed with a multiple screws and sideplates.  There is no evidence of
 hardware loosening or failure.  Alignment is unchanged.  No significant callus
 formation is identified, and the fracture lines remain visible.  Multiple skin
 staples are demonstrated along the anterior and lateral aspect of the distal
 leg.  Lucencies within the mid tibial diaphysis are secondary to prior
 external fixation hardware.

 LEFT FEMUR, FOUR VIEWS:  Comminuted fracture through the left femoral mid
 diaphysis is transfixed by an intramedullary rod with a single proximal gamma
 nail and two distal interlocking screws.  There is interval bridging callous
 formation about the fracture site, however, the fracture lines remain visible.
 The alignment is unchanged.  No evidence of hardware complications.


IMPRESSION:


Status post ORIF of multiple fractures as described above without
 change in alignment or hardware complications.

                                                                       DFDdp


Admission Date:  [**2147-5-30**]              Discharge Date:   [**2147-6-2**]

Date of Birth:  [**2093-6-1**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache

Major Surgical or Invasive


Procedure:


[**5-31**]: right craniotomy & evacuation of SDH


History of Present Illness:
53 yo M on [**2-25**] was carrying a heavy tub on his right
shoulder for a prolonged period.  He awoke with severe neck
pain.
He underwent an outpatient workup by his primary care physician
who ordered [**Name Initial (PRE) **] CTH when he began to exhibit neurologic symptoms,
personality changes and confusion.  He was called in to the ED
for evaluation of a right subacute on chronic subdural hematoma.

He denies history of trauma. Complains of right sided neck pain
and headache with valsalva, no nausea/vomiting, no
weakness/numbness, no visual disturbances.


Past Medical


History:


denies

Social


History:


lives with his wife, denies smoking, occasional
alcohol, no drugs of abuse


Family


History:


NC

Physical


Exam:


Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4->2mm bilat        EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam,
inappropriate affect
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
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 [**5-11**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin

Discharge:
non focal
dissolvable sutures, well healing


Pertinent Results:
Ct head [**5-27**] - 1. Chronic-appearing subdural hematoma at the
right frontovertex, with mass
effect and effacement of the underlying gyri and very mild
leftward subfalcine
herniation; this likely relates to the patient's clinical
presentation.
2. No more acute intra- or extra-axial hemorrhage.
3. Other than an incomplete enhancement of the lining membrane
of the
hematoma, no pathologic focus of enhancement.
4. No skull fracture.

Ct angiogram head/neck [**5-29**] - chronic SDH overlying the right
frontoparietal vertex measuring up to 13 mm in maximum
thickness, stable to slightly decreased in  size given slight
differences in technique when compared to [**2147-5-27**].
Effacement of underlying sulci with mild 2mm leftward shift of
midline
structures, improved. More acute 2 mm SDH overlying the left
frontal lobe,
stable. tiny scalp hematoma overlying the left vertex. no areas
of hypodensity
concerning for acute stroke.

CTA head and neck:
1. Right convexity subdural hematoma, small left subdural
hematoma, both
similar to [**2147-5-27**].

2. No significant vascular abnormality in the head or neck.

CT HEAD W/O CONTRAST [**2147-5-31**]
1. Status post evacuation of a right hemispheric subdural
hematoma, with
moderate pneumocephalus and small extraaxial fluid collection.
Stable mass
effect on the right cerebral hemisphere and right lateral
ventricle, without significant leftward shift of midline.
2. Stable thin left frontoparietal subdural hematoma.


Brief Hospital Course:
Patient was admitted to neurosurgery on [**5-29**] in the ICU for
further management.  He was loaded with dilantin and await
surgical intervention.   On [**2147-5-31**] he underwent a rightsided
craniotomy for evacuation of SDH under general anesthesia.  He
tolerated the procedure well, was exubated and transferred to
the PACU for Q1 hour neuro checks and SBP control less than 140.
 Postoperative Head CT showed some post operative changes with
pneumocephalus, but was otherwise stable. On [**6-1**], his exam was
intact and patient was transferred to floor. His diet was
advanced and he his foley was discontinued. Dilantin level was
7.5.
On [**6-2**] he was neurologically stable and cleared for discharge
home.

Medications on Admission:
ASA

Discharge Medications:
1. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Subacute on chronic SDH


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
General Instructions

??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
??????	You may shower before this time using a shower cap to cover
your head.
??????	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, and
Ibuprofen etc.
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, do not
resume taking this until cleared by your surgeon.
??????	If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week.  This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.


Followup Instructions:
Follow-Up Appointment Instructions

??????Your sutures are dissolvable and do not need to be removed.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2147-6-2**]


NPN Nights


#2 FEN- TF=150cc/kg/d PE28 with PM. abd benign. voiding. no
stool so far this shift. one sm spit. no asp. po 60cc. P-
Will cont to monitor FEN.
#4 G&D- Temp stable in open crib. [** 29**] and active with
cares. cobedding with sibling. sucking on pacifier. sleeping
well b/w cares. P- Will cont to monitor G&D.
#5 Parenting- No contact from [**Name2 (NI) **] so far this shift. P-
Will cont to encourage parental visits and calls.
See flowsheet for further details.


Micu Progress Note 1900-0700
pt is 49 yr old full code, NKMA, adm. [**6-23**] with SOB, febrile, and tachycardic chest X-ray showed LUL PNA. intubated on [**6-23**] for hypoxia. pt is now sedated and paralysed. complete white out on L. lung, ARDS picture. Hx of schizophrenia, HTN.

Events: was able to turn pt last night and seemed to tolerate it fine. will try to move him to rotation bed. cooling blanket on and pt temp went from 103.7 to 100.3. still waiting ID approval for rifampin which was ordered for UTI.

Neuro: pt sedated on versed of 8mg/hr and fentanyl 400mcghr. paralysed with cisatracurium of 0.1mg/kg/hr. Train of four on right facial nerve is [**4-12**]. pt does not respond to any stimuli, no cough, no gag. pupils equal and reactive, small 2mm sluggish.

Resp: intubated, AC 80/450/32/18. at 2200 O2 sat at 89%, ABG 7.21/75%/60/25. resident and attending notified of low O2 sat and ABG did not want to make any changes to settings. O2 sat 89-95%. suctioned mostly nothing from ET tube some scant tan thick secretions. no oral secretions. lung sounds rhonchi/inspitory wheezes. pt on vanco/ceftriaxone. will get repeat ABG at 0600 per resident.

Cardio: NSR/ST. did not have any episodes of SVT. HR 90-100's. HR came down as the fever did. SBP 80-130. levophed gtt turned off at 0400. MAPs 60-80's. sclera edema. pt positive 16 liters. CVP is really [**11-21**] since pt peep is so high. good peripheral pulses. T-max 103.7 currently in 100's, rectal temp, with cooling blanket on.

GI/GU: foley with amber/sediment urine. Urine culture pos. for legionella, did start Ripampin. UOP 25-240/hr. no bowel movement. gut movement is slow, cont to monitor OG residiuals. AT 0400 pt had 180 residuals, did waste 80 ml of this, refeed the rest. pt gets very few PO meds. TPN started yesterday. on insulin sliding scale.

Skin: pt skin is intact no breakdown noted, will try to move pt to rotation bed.

Social: sister is spokesperson, sister and mom speak [**Name2 (NI) 6610**]. no calls tonight but family was updated yesterday by doctors.

Acess: triple lumen IJ, 4 peripheral IV's. A-line. dressings/tubings changed

Plan: move pt to rotation bed for PNA/ARDS, monitor temp, monitor ABG's. monitor SBP to further keep Levo off. cont antibiotics for PNA and UTI. cont paralysis and train of four.


Sinus tachycardia and occasional ventricular ectopy.  Prior inferior myocardial
infarction.  Right bundle-branch block.  There is ST segment elevation in
leads II, III and aVF.  The myocardial injury may be recent.  No previous
tracing available for comparison.  Clinical correlation is suggested.


Nursing Progress Note


FEN:  Infant is waking about every 3-4 hrs for feedings.
Taking ad-lib amts of E24 (decreased calories d/t adequate
weight gain).  Infant is coordinated with feedings and
eating well, taking btn 60-75cc each feeding.  Voiding QS,
passing stools.

Dev:  Temp stable swaddled in crib.  Infant is sleeping well
between feedings and is very active with cares. Infant
occasionally wakes between cares but falls back to sleep
with pacifier.  Infant is appropiate with cares.  Will cont
to support dev needs.

[** 2**]:  No family contact as of this writing.  Will
confirm family meeting when [** **] call.

Potential for withdrawl:  [** **] given Q4 hrs as ordered,
weaned today.  Infant [**Doctor Last Name 2452**] [**4-18**] on NAS scores hypertonic,
mottles with cares and coloring is slightly grey.  Plan to
cont to monitor, monitor tolerance of wean.


Sinus rhythm. Since the previous tracing anterior T wave abnormalities are
now present.  Clinical correlation is suggested.
TRACING #2


Sinus bradycardia. Prolonged A-V conduction. Left bundle-branch block pattern
although the QRS interval is slightly narrower than that seen on [**2199-1-5**].
TRACING #2


Baseline artifact.  Sinus rhythm.  Left bundle-branch block.  Atrial
premature beats with aberrant conduction giving rise to right bundle-branch
block type beats.  Alternatively, sinus rhythm and ventricular premature
beats resulting in the relatively [**Name2 (NI) 10**] QRS complex appearing intermittent
beats.
TRACING #1


[**2124-9-19**] 9:22 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 87587**]
 Reason: ngt placement
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


89 year old man with large bowel obstruction, central line for tpn and ivf


REASON FOR THIS EXAMINATION:


ngt placement
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Large bowel obstruction, new central line.

 PORTABLE AP CHEST: A left subclavian central venous line terminates at the
 cavoatrial junction.  There is no pneumothorax. Nasogastric tube tip overlies
 the stomach. The heart is enlarged but stable.  Compared to radiograph from
 approximately 7.5 hours earlier today there has been progression of
 predominantly perihilar interstitial and alveolar opacities consistent with
 worsening CHF.  There is dilatation of the visualized transverse colon,
 consistent with known bowel obstruction.


Nursing Progress Note 0700-1900
Events: HD removing 3.5liters tolerated well without hypotension. Pt emotionally labile, occas crying and talking about death. ? Panic attack @ 1400 assoc with mucous plug, CXR unchanged and O2 sat and volumes remained WNL.

Review of Systems:

Neuro: [**Name (NI) 516**] pt on Versed 1.5mg, Fentanyl 75mcg/hr. Pt intermit C/O back pain, relieved with repositioning. Fentanyl patch of 50mcg added in anticipationn of weaning drips off. Versed weaned down to 1mg @ 1700. Pt C/O HA in afternoon, relieved by Tylenol 650mg X 1. Pt emotionally labile per above, occas crying and asking if he's dying. He also expressed distrust of hospital personel, and was reassured that we are all trying to help him get better so he can return home. Trach cuff intermit deflated to allow pt to easily talk with staff.

Resp: [**Name (NI) 516**] pt on vent settings AC 40%/14 X 550/+5 with rare overbreathing. Lung snds clear in upper airways, diminished in bases. Pt required sxn'ing Q1-2hrs for mod-lg amts thick/white secretions. Cough raising secretions well. At 1400 pt C/O extreme resp distress with SBP to 180's. O2 sat remained 100% and vT unchanged, however pt with copious thick, white secretions via ETT and lung snds coarse with scattered wheezes. Resp therapist lavaged ETT and removed blood-tinged plug. CXR unchanged. Pt given inhalation tx and responded well with eventual return to baseline. Pt then placed on PS 10/+5/40% with following ABG 7.45/39/179.

CV: HR 81-120SR without VEA. BP 134/61-157/90. AM Na 136, free water bolus decreased. Tmax 98.7ax.

GI: Abd obese, soft/distended with + bowel snds. TF of Nutren Pulm @ goal 30ml/hr via PEG with small residuals. Mushroom cath draining mod amts liquid brown stool.

GU: HD tolerated well per above, removing 3.5liters. Urine yellow/clear, draining @ avg 5ml/hr. Fluid balance for LOS +8.6liters.

Social: Aunt in and pt apologizing for hurting her son, with Aunt accepting apology. Pt freq requesting mother who has not arrived. Nurse spoke with pt's [**Last Name (LF) **], [**First Name3 (LF) **], who will visit this evening.

Plan: Cont aggressive pulm toilet, and attempt to keep HOB @ 30degrees though pt dislikes head elevated. Freq reassure and reorient pt. Deflate cuff briefly to allow pt to express feelings, await PMV. Cont prep for D/C to rehab ? Monday.


Normal sinus rhythm with prolonged A-V conduction.  Prominent U waves.
Otherwise, normal tracing.  No significant difference from previous tracing
other than precordial T waves in leads V1-V2 are now normal.  Normal tracing.


Sinus rhythm.  Probable left ventricular hypertrophy with associated
ST-T wave changes.  Compared to the previous tracing there is no significant
change.


[**2109-3-20**] 12:14 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 73**] # [**Clip Number (Radiology) 28936**]
 Reason: eval tube placement
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


[**Age over 90 **] year old man with new intubation


REASON FOR THIS EXAMINATION:


eval tube placement
 ______________________________________________________________________________


FINAL REPORT


REASON FOR


EXAMINATION:


Evaluation of ET tube placement.

 Portable AP chest radiograph was compared to prior study obtained the same day
 earlier at 10:25 a.m.

 The ET tube tip is approximately 5 cm above the carina.  The cardiomediastinal
 silhouette is stable.  There is opacity in the left perihilar area that given
 its rapid development is most likely concerning for aspiration.  Bibasilar
 retrocardiac atelectasis is unchanged.  Lung volumes have increased in the
 interim that most likely related to the intubation.  The NG tube tip passes
 below the diaphragm, most likely terminating in the stomach, although its tip
 is below the inferior margin of the field of view.


MICU NPN 11P-7A
NEURO: AAO X3. DENIES PAIN. MOVING ALL EXTREMITIES WEAKLY. GIVEN AMBIEN FOR SLEEP WITH GOOD EFFECT. ON LACTULOSE.

CARDIAC: HR 87-94 SR WITH NO ECTOPY. BP 142-155/66-92. TOLERATED INCREASE IN LOPRESSOR. PPP. HCT 29. HEPARIN 650U/HR. PTT AT MIDNOC WAS 31, GIVEN 900U BOLUS AND INCREASED GTT TO 900U/HR. AM PTT WAS 46. NO SIGNS OF BLEEDING.

RESP: ON RA WITH RR 14-26 AND SATS 95-98%. LS CLEAR WITH DIMINISHED BASES. DENIES SOB. TOLERATING ACTIVITY AND LYING FLAT IN BED.

GI/GU: ABD SOFT AND DISTENDED WITH +BS. SMALL SOFT STOOL. MINIMAL UOP AMBER AND CLEAR. CREAT 3.3 S/P HD.\

FEN: SEE CAREVUE FOR LYTES. TAKING PO'S WELL. PATIENT HAD NOT RECEIVED PM GLARGINE. FS AT MIDNOC 151 AND 6AM 227. NOT COVERED AS HE IS COVERED AT MEALTIMES.

ID: TMAX 9, TEMP 98.8. ON CONTACT PRECAUTIONS. RECEIVED HIS VANTIN AFTER HD.

SKIN: ABRASIONS TO COCCYX.

ACCESS: PIV X1, LSC PERMACATH, RIGHT FEM CVL.

SOCIAL/DISPO: FULL CODE. NO CONATCT FROM FAMILY. ?CALL OUT TO FLOOR.


NP NOTE
PE: small growing preterm infant swaddled in isolette. Pink, well prefused in RA.
[** 158**] sutures split, eyes clear, ng in place, MMMP
Chest is clear, equal bs, comfortable
CV: RRR gr3/6 systolic murmur LLSB, pulseS +2=
Abd: soft with active bs
GU: immature female
ETX: [**Last Name (LF) 98**], [**First Name3 (LF) 99**]
Neuro: flexed posture, symmetric tone and primiive relfexes.


[**2185-7-10**] 11:27 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 54704**]
 Reason: Check new line position
 Admitting Diagnosis: CHOLANGIOCARCINOMA\ PTC/SDA
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


63 year old man with PA line changed over wire to cvl


REASON FOR THIS EXAMINATION:


Check new line position
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST [**2185-7-10**]


CLINICAL INDICATION:


Line placement.

 Comparison is made to previous radiograph of 2 days earlier.

 A right internal jugular vascular catheter has been placed, terminating in the
 lower SVC near the junction of the right atrium. No pneumothorax is
 identified. Cardiac and mediastinal contours are stable. There are bilateral
 small pleural effusions, increased on the left and new on the right. There are
 also increasing opacities in the retrocardiac region bilaterally.


IMPRESSION:


1) Vascular catheter in satisfactory position, with no pneumothorax.
 2) Bilateral pleural effusions, increased on the left and new on the right.
 Adjacent basilar lung opacities likely reflect atelectasis, but other process
 such as an infection cannot be excluded in the appropriate setting.


NNP Physical Exam
Awake and alert. AFOF with good tone and activity. Breath sounds clear and equal with slight retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with active BS, no HSM or masses. Normal GU.


s/p right embolectomy with patch angioplasty
O: arrived on milrinone .5mcq, amiodarone 1 mg, neo @ .4mcq, svo2 61, placed on 10 mcq propofol.heparin initiated @ 500 units/hr without a bolus. ptt prior to initiation came back @ 63, repeat ptt pending.
cardiac: av paced underlying rythym 31. neo off presently, sbp 110's. ct drainage minimal, ci>2. dsgs d+i. doppler pp left, right foot cold to touch to ankle, slightly cool @ knee no further cyanosis of right knee. absent pt , swoosh weak dp, vascular md's into assess pt. calcium replaced x1.
resp: cxr done - ho assessed , sx for a scant amount of tan sputum after being lavaged, presently clear upper, diminished bibasilar. po2 on 80% 94 dropped to 70%. peep to be increased. o2 sats >98%. no ct leak.
neuro: sedated , continues on propofol @ 20 mcq. perl brisk.
gI: ngt to lcs with 25 mlbilious drainage, positive placement,absent bowel sounds.
gu: good uo,
endo: sliding scale insulin , to start insulin gtt.
skin: dsgs d+i.
social: wife phoned and updated.
a: weak intermittent right dp pulse, ci>2. underlying rythym 30's, decreased po2 on high fio2.
p: monitor comfort, hr and rythym, sbp, ct drainage, pp- vascular to be notiifed if absent or change, I+O, institute insulin gtt, labs , as per orders.


NPN 1900-0700


FEN:  BW 1460g  CW 1405g (up 5g).  TF 120cc/kg/day.  EF
currently at 40cc/kg/day BM20; advancing by 10cc/kg [**Hospital1 **].
PIV replaced at 2100 due to leaking and puffiness.  PIV Rt
foot patent and infusing PND10 + IL at 80cc/kg/day.  DS= 55,
62.  Appears to be tolerating PG feeds well.  No spits, min
asp.  Abd benign.  AG= 20cm.  8hr UO= 2.9cc/kg/hr, lg mec
stool x1.  Lytes and Trig sent at 0500; results pending.

DEV:  Temps stable while [**Hospital1 **] in servo isolette.  A/a with
cares, irritable at times btwn.  Settles with hand
containment and pacifier.  Moves hands to face.  [**Last Name (LF) 383**], [**First Name3 (LF) 57**].

PAR:  Mom in for brief visit at [**2051**].  Updated at bedside by
this RN.  Asking approp questions.  Family mtg scheduled for
today at 1430.  Continue to support and update [**Year (4 digits) **] as
needed.

[**Year (4 digits) **]:  Pt continues under Neoblue PhotoRx.  Eye mask in
place.  Pt appears ruddy/jaundiced, working up on feeds.
Mec stool x1.  Repeat [**Year (4 digits) **] sent at 0500, results pending.
[**Year (4 digits) **] yesterday 8.2/0.2.  Continue to monitor.


[**2116-12-12**] 5:40 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 72557**]
 Reason: ? interval change
 Admitting Diagnosis: ESOPHAGEAL CANCER/SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


22M with R CT


REASON FOR THIS EXAMINATION:


? interval change
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST, [**2116-12-12**]

 CLINICAL INFORMATION:  Right chest tube.


FINDINGS:


Comparison is made to the prior study from [**2116-12-11**].  A right-sided chest
 tube is positioned with the tip near the right lung apex.  There is a patchy
 focus of airspace opacity in the right mid lung zone.  Since the prior study,
 there has been interval development of increased pneumothorax, approximately
 10 to 15% at this time.  Left lung is relatively clear.


TITLE:
   Demographics
   Day of intubation:
   Day of mechanical ventilation: 0
   Ideal body weight: 72.6 None
   Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg
   Airway
   Airway Placement Data
   Known difficult intubation:
   Procedure location: OR
   Reason: Elective
   Tube Type
   ETT:
                   Position: 23 cm at teeth
                   Route: Oral
                   Type: Standard
                   Size: 7.5mm
   Tracheostomy tube:
                   Type:
                   Manufacturer:
                   Size:
                   PMV:
   Cuff  Management:
                   Vol/Press:
                                   Cuff pressure:   cmH2O
                                   Cuff volume:   mL /
                   Airway problems:
                   Comments:
   Lung sounds
   RLL Lung Sounds: Clear
   RUL Lung Sounds: Clear
   LUL Lung Sounds: Clear
   LLL Lung Sounds: Clear
   Comments:
   Secretions
   Sputum color / consistency:  /
   Sputum source/amount:  /
   Comments:
   Ventilation Assessment
   Level of breathing assistance: Continuous invasive ventilation
   Visual assessment of breathing pattern: Normal quiet breathing
   Assessment of breathing comfort: No response (sleeping / sedated)
   Non-invasive ventilation assessment:
   Invasive ventilation assessment:
   Trigger work assessment: Not triggering
   Dysynchrony assessment:
   Comments:
   Plan
   Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;
   Comments: pt recieved intubated from OR, plan is to wean via fast track
   protocol through PM
   Reason for continuing current ventilatory support: Sedated / Paralyzed
   Respiratory Care Shift Procedures
   Transports:
   Destination (R/T)
   Time
   Complications
   Comments
   Bedside Procedures:
   Comments:


This is a 58 yr old male with a history of HTN, COPD,HCV and ETOH abuse
   who was found slumped over  on a park bench  smelling of alcohol.  He
   admits to drinking all day but denies trauma. Initial SBP in the
   90
s..dropping to the 70
s despite 4 liters of IVF. Slow response to
   narcan. ABG 7.26/50/76/23.  Protecting airway, more awake upon
   arrival,  insp/exp wheezes throughout. Transfer to CCU for close
   observation of ETOH withdrawal. CIWA  assessment  in place q2 hours.
   ETOH level 262 on admission. Urine tox positive for benzos; Initially ?
   sepsis
 antibx given, remains on Levophed, Vanco D/c
d this am as BP,
   Hr stable.
    Pt awake, alert, oriented, and cooperative this morning; CIWA 13 or
   less w/minor c/o HA and nervousness; receiving po Valium prn; transfer
   for further observation to floor.
   Alcohol withdrawal (including delirium tremens, DTs, seizures)
   Assessment:
   Mild symptoms of ETOH withdrawl, well managed thus far with Valium ~
   10mg po Q 1hr
   Action:
   CIWA scale Q1-2hr
 medicate with Valium as ordered
   Response:
   CIWA scale has remained 13 or less, pt is awake, alert, and oriented,
   cooperative
   Plan:
   Transfer to medical floor for continued observation.
   Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)
   with acute exacerbation
   Assessment:
   Pt with a 3l n/c O2 requirement with insp/exp wheezes
   Action:
   Atrovent/Albuterol nebs Q4-6hrs;  Fluticasone inhalor  [**Hospital1 **]
   Response:
   Sats in mid 90
s at rest but can desat briefly to 88-90
s w/exertion
   Plan:
   Continue to follow sats, Cont nebs Q4hr, inhalors, also on Levoflox to
   cover upper respiratory illness.


NPN 0700-1900


#1 Resp: Infant continues in RA, RR 30-60, sats >96%. Lungs
cl/=. Mild SCR. No spells. Plan: Continue to monitor resp
status.

#2 FEN: TF 130/kg of SC28 alternating PO/PG. At 1300 pt took
20cc PO (remainder gavaged). Pt dribbled and tired easily.
Abd soft, [** 467**], round. No spits, HOB 45 degrees. Max
aspirate 2cc. Voiding, stooling, heme neg. Plan: Continue to
encourage PO feeding as tolerated.

#4 Dev: Maintaining temp in OAC. [** **] and active with
cares. Due for 60-day immunizations on [**3-21**]. Enjoys binky.
Plan: Continue to support dev needs.

#5 Social: Mom called this AM. Updates given. Plan: Continue
to support and educate [**Month/Year (2) 26**].


Subjective
   Nausea, limited po intake PTA d/t diarrhea and nausea
   Objective
   Height
   Admit weight
   Daily weight
   Weight change
   BMI
   173 cm
   82 kg
   86.8 kg ([**2192-9-12**] 02:00 AM)
   27.4
   Ideal body weight
   % Ideal body weight
   Adjusted weight
   Usual body weight
   % Usual body weight
   69.9 kg
   117%
   79.5
   103%
   Diagnosis: bowel obstruction
   PMH : major recurrent depression, prostate Ca with mets to spine,
   chronic constipation, gastric volvulus s/p gastropexy, hiatal hernia
   s/p ventral hernia repair
   Food allergies and intolerances:  NKFA
   Pertinent medications: RISS, pantoprazole, mag sulfate x 1, KCl x 1
   Labs:
   Value
   Date
   Glucose
   85 mg/dL
   [**2192-9-13**] 02:56 AM
   Glucose Finger Stick
   88
   [**2192-9-13**] 09:00 AM
   BUN
   61 mg/dL
   [**2192-9-13**] 02:56 AM
   Creatinine
   2.4 mg/dL
   [**2192-9-13**] 02:56 AM
   Sodium
   138 mEq/L
   [**2192-9-13**] 02:56 AM
   Potassium
   3.8 mEq/L
   [**2192-9-13**] 02:56 AM
   Chloride
   107 mEq/L
   [**2192-9-13**] 02:56 AM
   TCO2
   21 mEq/L
   [**2192-9-13**] 02:56 AM
   PO2 (arterial)
   89.[**Numeric Identifier 126**] mm Hg
   [**2192-9-13**] 03:22 AM
   PCO2 (arterial)
   30 mm Hg
   [**2192-9-13**] 03:22 AM
   pH (arterial)
   7.47 units
   [**2192-9-13**] 03:22 AM
   CO2 (Calc) arterial
   22 mEq/L
   [**2192-9-13**] 03:22 AM
   Calcium non-ionized
   7.9 mg/dL
   [**2192-9-13**] 02:56 AM
   Phosphorus
   3.1 mg/dL
   [**2192-9-13**] 02:56 AM
   Ionized Calcium
   1.10 mmol/L
   [**2192-9-13**] 03:22 AM
   Magnesium
   1.9 mg/dL
   [**2192-9-13**] 02:56 AM
   WBC
   10.7 K/uL
   [**2192-9-13**] 02:56 AM
   Hgb
   9.5 g/dL
   [**2192-9-13**] 02:56 AM
   Hematocrit
   27.2 %
   [**2192-9-13**] 02:56 AM
   Current diet order / nutrition support: NPO
   GI: NGT draining abd distended
   Assessment of Nutritional Status
   At risk for malnutrition
   Pt at risk due to: NPO / hypocaloric diet
   Estimated Nutritional Needs
   Calories: 1749-[**2171**] (BEE x  or / 22-25 cal/kg)
   Protein: 64-79 (0.8-1.0 g/kg)
   Fluid: per team
   Estimation of previous intake: Inadequate
   Estimation of current intake: Inadequate
   Specifics:
   Medical Nutrition Therapy Plan - Recommend the Following
   Multivitamin / Mineral supplement: in TPN
   Tube feeding / TPN recommendations:
   Check chemistry 10 panel daily
   Comments:


Neonatology Attending

Day 10  PMA 36 0/7 wks

Remains in RA.  RR 30-60s.  Sats >96%.  Clear breath sounds.  Had one bradycardia episode overnight.  No murmur.  HR 130-150s.  BP mean 46.  Weight 2340g (+30).  TF at 150 ml/kg/d- BM 24- po/pg.  Taking minimal volume by bottle.  Passing heme negative stool.  On iron.  Stable temperature in open crib.  Parents in daily.

Doing well overall with minimal respiratory immaturity.  Monitoring closely.  Gaining weight well.  Learning to feed.


NPN 07:00-19:00 MICU
*Please refer to Carevue for additional patient information.
*Full Code

*Shift Events:
Pt became increasingly tachypneic as day progressed, requiring mask ventilation now on Cpap+PS 5/FiO2 40%/TV 800, RR ^20's-low 30's. LS diminshed throughout, w/ expiratory wheezes noted. Natrecor .02mcg/kg/min started this afternoon, as well as Nitroglycerin goal SBP ~120 per Dr. [**Last Name (STitle) 1176**]. LIJ place, wnl, per Dr. [**Last Name (STitle) 1176**] ok to access.Plan: Monitor Resp status, u/o (fluid status).

ROS:
Neuro: A/O x3, MAE's, restraints in place d/t pt grabbing for face mask. Increase anxiety this evening, written for MSO4 to "take edge off", will give.
CV: V-paced HR 60's, PVC's rare, SBP 170's, now on Nitro gtt w/ goal of SBP ~120. Natrecor .02mcg/kg/min. Afebrile.
Resp: Early in shift on 2L NC, now on Face mask/CPAP 5, O2 sat's high 90's, RR 20-30, LS diminished.
GI/GU: Written for REnal diet, taking small amount of food prior to Mask ventilation, C/O stomach cramping given PO med w/ good effect, Diarrhea x2 guiac negative, pndg stool/c-diff from yesterday stool being sent. U/O ~30cc/hr, yellow w/ sediment.
Access: Please see carevue
Social: Family updated on pt's status.


[** 1**] Physical Exam
PE: pale pink, AFOF, breath sounds clear/equal with mild subcostal retracting, soft murmur audible throught lung fields(PPS), normal pulses and perfusion, abd soft, full, non tender, + bowel sounds, active with good tone.


[**2101-2-16**] 12:04 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 83921**]
 Reason: assess for infiltrate, pulmonary edema
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


88 year old woman with h/o CAD p/w CP, SOB, hypoxic to low 90s


REASON FOR THIS EXAMINATION:


assess for infiltrate, pulmonary edema
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


88-year-old female with history of CAD with chest pain and
 shortness of breath and hypoxia.


COMPARISON:


CXR [**2101-2-6**].

 AP ERECT PORTABLE CHEST:  The patient is status post median sternotomy and
 CABG.  Dual-lead pacemaker is unchanged in position.  The pulmonary
 vascularity appears stable.  A new left lung opacity obscures the left heart
 border.  There is no pleural effusion or pneumothorax.


IMPRESSION:


New left lingular opacity, worrisome for pneumonia.


Neonatology Attending

Day 4  PMA 39 [**2-5**] wks

Remains on nasal cannula oxygen at 100 cc/min, 30% oxygen.  RR 30-40s.  Mild retractions.  Clear breath sounds.  No murmur.  HR 120-150s.  Jaundiced.  Bilirubin 7.5/0.3.  Last hct 42.  BP mean 56.  Weight 3920 g (-45).  IV hep locked.  Ad lib feeds of 40-60 ml per feed every 4 hours.  Also put to breast.  Benign abdomen.  No spits, stool.  Stable temperature in open crib.

Doing well overall.  Weaning oxygen.  Will switch to low flow nasal cannula.  Will continue to monitor closely.  No evidence of bleeding.  Improved feeding.  Family up to date.


This is a 51M with HTN, OSA, morbid obesity now with acute onset of
   hypoxic hypercarbic respiratory failure and fever with leukocytosis and
   bandemia. CTA ruled out for PE. LENI neg for DVT.CT abdomen with no
   [**Last Name (un) **] process.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   Received on vent settings CMV 20/500/50%/PEEP 14.  O2 sats 88-92%.
   Suctioned for moderate amt of thick, tan secretions.  LS diminished
   throughout.  Tmax 100.1 PO.
   Action:
   Suctioned q 2-3 hrs.  Continued on antibiotics.  SBT done. ABG
   7.43/54/65.  Extubated and placed on face tent @ 70% and NC @ 5L.
   Encouraged CDB.  OOB to chair with PT.
   Response:
   O2 sats 90-95% on face tent @ 70% and NC @ 5L. LS diminished. Strong
   cough/gag.  Raspy voice.
   Plan:
   Continue to encourage CDB.  Wean O2 as tolerated.
   Impaired Skin Integrity
   Assessment:
   Left leg cellulitis (warm, red, intact) looks improved from
   demarcation.
   Action:
   Monitored site. Cleaned and kept open to air.
   Response:
   No change noted.
   Plan:
   Cont. skin care, use rotation on bed.
   Hypertension, benign
   Assessment:
   MAPs 101-136.
   Action:
   Continued on lopressor and captopril. Team aware.
   Response:
   MAPs decreasing once extubated.
   Plan:
   Continue lopressor and captopril. ? adding home BP meds if BP continues
   to be elevated.


[**2175-3-6**] 4:24 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 48138**]
 Reason: Eval for reaccumulation of effusion
 Admitting Diagnosis: ASCITES
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


58 year old man with EtOH cirrhosis.  s/p R thoracentesis for pleural
  effusion  s/p drainage [**3-3**], w/ hypoxia.


REASON FOR THIS EXAMINATION:


Eval for reaccumulation of effusion
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Status post right thoracentesis, evaluate for reaccumulation or
 effusion.


COMPARISON:


[**2175-3-4**].

 PORTABLE CHEST RADIOGRAPH

 Cardiac and mediastinal contours appear stable.  There is persistent moderate-
 to-large right pleural effusion, not significantly changed in size from prior
 study allowing for technical differences.  Left lung remains relatively clear.


Sinus rhythm.  ST-T wave changes consistent with left ventricular hypertrophy,
although ischemia or infarction cannot be excluded.  There are small R waves in
the anterior leads consistent with possible prior myocardial infarction.
Compared to the previous tracing of [**2126-5-14**] ventricular ectopy is no longer
present and the P-R interval is shorter.
TRACING #1


CCU Nursing Progress Note
Neuro:  Pt sedated on 20 mcg propofol.  Pt awoke on 15 mcg and began to tear.  Pt able to follow some commands inconsistantly.  Pts Pupils vary between differing sizes and reactiveness.  Pt able to move all extremeties, on own will.

Cardiac:  Pt in AF HR in the 90's-100's, BP 112-141/40-45 MAP 61-70, CVP 1-5 (slightly positional), Pt on 1mcg dopa and 15mcg [**Name (NI) **], pt required 500cc fluid bolus x2 for low MAP and CVP.  PA 32-38/13-17, wedge 7.  CO/6.3, CO/3.3, SVR/711.  Cardiac meds on hold while pt on pressors.

Resp:  Pt intubated on AC 18, 700, .4%, 5/; MV 70.  Pts BS are coarse, pt suctioned x1 for mod amt thick brown sputum.  ABG in am 7.4, 33, 122.

GI:  Possibly start TF today.  Nepro with 70g Promode goal of 50?.  Abd soft NT, hypoactive BS -BM.  Pt con't to have BRB when suctioning oral pharynx.  Pt has OGT tolerating meds.

GU:  Restart CVVHDF in am.  Pt essentilally anuric.  Urine brown with sediment via f/c.

ID:  Pt con't on [**Name (NI) 4222**], vanco, and ceftaz; ampicillin dc'd.  Pt afebrile, t-max 37.2 core.  Pt has G+ cocci in pairs, clusters, and chains and G+ rods in sputum, Enterococcus in urine, staph from cath tip of R fem.

Heme:  Coags under much better control.  Will restart heparin with CVVHDF today.  Monitor colsely.  HCT stable.

[**Name (NI) 505**]:  BG under much better control; coverage needed, BG max 201.

Dispo:  Pt remains Full Code!


SOCIAL WORK NOTE:
Left pt's wife, [**Name (NI) 3717**], a message at home in NH to offer continued support.  Will remain involved as needed.  Pager [**Numeric Identifier 341**].


CVA (Stroke, Cerebral infarction), Ischemic
   Assessment:
   Pt with slightly improved neurological status from previous shift, Pt
   follows some commands, moves all limbs on bed, able to lift and hold
   right arm.  On trach mask.
   Action:
   Q4hr checks.
   Response:
   Continues to appear brighter in self.
   Plan:
   Maintain on Trach mask overnight, c/o to floor/rehab.


[**2168-1-21**] 7:30 AM
 NEONATAL HEAD PORTABLE                                          Clip # [**Clip Number (Radiology) 86228**]
 Reason: PREMTURITY, R/O PVL
 Admitting Diagnosis: NEWBORN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


Infant born at 25 weeks, now 38 weeks CGA


REASON FOR THIS EXAMINATION:


r/o PVL
 ______________________________________________________________________________


FINAL REPORT


HEAD ULTRASOUND

 Images were obtained in coronal and sagittal planes and compared to the prior
 study of [**11-16**].  The ventricles remain normal in size.  No evidence of
 subependymal, intraventricular or intraparenchymal hemorrhage is seen.  The
 extraaxial spaces are normal.


IMPRESSION:


Normal cranial ultrasound.


Neonatology Attending

DOL 10

Stable in RA.  1 A/B.

On 150 cc/kg/d BM 26.  Voiding.  Stooling.  Wt 1590 grams (up 45).

Continues on pcn d10/10

Parents visiting and up to date.

A:  Stable.  Mild apnea of prematurity not requiring treatment. GBS sepsis treated.

P:  Continue monitoring.
    Add promod
    D/C pcn after today's doses complete


Sinus tachycardia.  Low lateral precordial voltage of uncertain significance,
possibly related to lead position.  No previous tracing available for
comparison.  Clinical correlation is suggested.  No previous tracing available
for comparison.


Sinus rhythm
Premature ventricular contractions
Probable anteroseptal infarct - age undetermined
ST-T wave abnormalities
Since previous tracing of [**2151-6-22**], no significant change


Respiratory Care Note
Pt received from OR intubated and placed on AC as noted per anesthesia. BS essentially clear and equal. ABG's reveal severe respiratory acidosis. IMV increased accordingly. Pt transported to CT Scan for head and abdomen without incident. Pt weaned to PSV and from sedation. ABG's are improved. Pt suctioned for moderate amt thick, white secretions from ETT. Subglottic suctioning done for copious amts thick, bloody secretions. Pt extubated without incident to cool aerosol.


Neonatology NP Note
PE
swaddled in open crib
AFOf
comfortable respirations in room air, lungs clear/=
RRr, no murmur, pink and well perfused
abdomen soft, nontender and nondistended, active bowel sounds
small umbilical hernia
active with good tone


Newborn Med Attening

Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1765 up 10, on 150 cc/kg BM30 with PM.
A/P: Growing infant working up on PO feeds.


Unit No:  [**Numeric Identifier 61005**]
Admission Date: [**2173-4-17**]
Discharge Date: [**2173-5-2**]
Date of Birth:  [**2173-4-17**]
Sex:  F
Service:  NB


HISTORY OF PRESENT ILLNESS:  Baby girl [**Known lastname 13950**] is the 2.365
kilogram product of a 33 and [**6-22**] week gestation born to a 28-
year-old G3/P now 2 mom. Prenatal screens of A positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis
surface antigen negative, GBS positive in last pregnancy.

PAST OBSTETRICAL


HISTORY:


Notable for previous preterm C-
section delivery due to arrest of descent. Current pregnancy
complicated by premature rupture of membranes since [**2173-4-1**]. Mother was beta complete. The decision was made to
proceed with cesarean section today as infant was almost 34
weeks and increasing concern and risk of chorioamnionitis at
this point. Surgery notable for multiple adhesions. Required
only blow-by O2 and routine care in the OR. Apgar's were 8
and 9.

PHYSICAL EXAMINATION ON ADMISSION:  2.365 kilograms (60th
percentile), length 44.5 cm (50th percentile), head
circumference 32.25 cm (75th percentile). Anterior fontanel
soft/flat. Red reflex deferred. Palate intact. Minimal
intercostal retractions. Breath sounds clear and equal.
Regular rate without rhythm. Peripheral pulses of 2+;
including femoral's. Abdomen benign without
hepatosplenomegaly. No masses. Hips deferred. Normal female
external genitalia for gestational age. Skin pink and well
perfused. Normal tone and strength for gestational age.

SUMMARY OF HOSPITAL COURSE BY SYSTEM:
RESPIRATORY: Cloie has been stable in room air throughout her
hospital course.

CARDIOVASCULAR: Has been stable without issue.

FLUIDS, ELECTROLYTES AND NUTRITION: Was initially started on
60 cc/kg per day of D-10-W. Advanced to full enteral feedings
by day of life #4. Is currently taking ad lib feedings of 150
cc/kg per day of breast milk or Special care similac 24
calories. Her discharge weight is 2515 gms.

HYPERBILIRUBINEMIA: Her peak bilirubin was on day of life #4
at 13.2/0.3. Received phototherapy, and her rebound bilirubin
was within normal limits.

HEMATOLOGY: Hematocrit on admission was 47.3. She did not
require any blood transfusions during this hospital course.

INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign. Blood culture remained negative at
48 hours, at which time ampicillin and gentamicin were
discontinued.

NEUROLOGY: The infant has been appropriate for gestational
age.

AUDIOLOGY: A hearing screen was performed prior to
discharge and passed in both ears.

PSYCHOSOCIAL: A social worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].

CONDITION ON DISCHARGE:  Good.

DISCHARGE DISPOSITION:  To home.

NAME OF PRIMARY PEDIATRICIAN:  Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52383**] (telephone
number [**Telephone/Fax (1) 61006**])

CARE RECOMMENDATIONS:
1. Feedings at discharge: Continue ad lib feedings; breast
   milk 24-calorie concentrated with Similac powder or
   Similac 24-calorie.
2. Medications: None.
3. Car seat position screening was performed, and the infant
   passed.
4. State newborn screen has been sent per protocol and has
   been within normal limits.


IMMUNIZATIONS RECEIVED:  The infant received the first
hepatitis B vaccine on [**2173-4-27**].

IMMUNIZATIONS RECOMMENDED:  Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks gestation; (2) born between 32 and 35 weeks with 2 of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; or  (3) with chronic lung disease.

Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.

DISCHARGE DIAGNOSES:
1. Premature infant born at 33 and 6/7 weeks.
2. Status post rule out sepsis with antibiotics.
3. Mild hyperbilirubinemia.




                        [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]

Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D:  [**2173-5-1**] 01:05:59
T:  [**2173-5-1**] 08:46:16
Job#:  [**Job Number 61007**]


Neonatology Attending Progress Note:
DOl #4
PMA 25 4/7 weeks
on HFO MAP=9, amp=16, 25-29%FiO2
last gas:  7.27/52/65/-3
no spells
on vitamin A
s/p first course indomethacin with moderate PDA on recent echo
HR=140-170's, MAP=32-40, recent BP 49/26 (mean=35)
last transfused on [**9-19**]
double phototherapy, last bili=2.6/0.4
on day #4/14 amp and gentamicin, cultures negative to date
wt=613 (inc 10g), TF=160cc/kg/d.  PN D11/Il
fentanyl 2 mcg/kg/hr
peripheral IV and UA line
voiding 3.0 cc/kg/hr, no stool
remains NPO

PE:  active, bagged off HFO during exam.  intermittent ??murmur noted with intermittent bounding pulses. breath sounds slightly decreased but equal, abdomen softly distended, mild duskiness, extremities well
perfused. tone aga

136/3.8/102/21
HC=21.5cm (unchanged)

Imp/Plan: premie infant with intraparenchymal hemorrhage, surfactant deficiency, resolving PDA, indirect hyperbilirubinemia, probable sepsis, s/p hypotension, remains critically ill
--will attempt conventional ventilation today
--will need LP when stable
--continue double phototherapy
--HUS at 1pm today, measuring Head circumference, need to assess if bleed is stable
--lytes, bili, crit in am
--in setting of mild duskiness on exam as well as worsening [**Last Name (LF) 4001**], [**First Name3 (LF) 31**] not treat today if signs of PDA and consider echo in am if signs of PDA.  at this point no signs of PDA but will continue to monitor for this.  will check KUB today and closely follow abdominal exam--extremely soft and nontender, nondistended
--continue amp and gentamicin to complete 7 day course
--will consider echo


Nursing progress note

1 Altered Resp. Status

#1 O: Remains in RA with lungs clear and equal with good
aeration to bases, breathing with very mild SC retractions
with RR-40-50's A: without compromise P: monitor per normal
newborn
#4 O: Awakening for cares and crying to be fed, loves to be
held and spoken to with [**Female First Name (un) 1590**] calming down and gazing at
caretaker, sleeping well between cares A: AGA P: provide
developmental care and interventions, EI called in for
planned discharge on [**2153-2-17**]
#5 O: Dad phoned to inquire about [**Female First Name (un) 1590**], stated would be in
later tonight with carseat for test, arranged with [**Female First Name (un) **]
for discharge teaching with interpreter on [**2153-2-17**] at 1300,
VNA and EI called in, dad to make appointment with private
pediatrician for [**2153-2-19**] A: [**Month/Day/Year **] preparing to take [**Female First Name (un) 1590**]
home P: provide teaching and support to family in
preparation for discharge [**2153-2-17**]
#6 O: Awakening for feedings, feeding well, voiding and
[**Month/Day/Year **] A: Feeding well, adequate intake for growth P: wt.
daily and feed on demand

REVISIONS TO PATHWAY:

  1 Altered Resp. Status; resolved


pmicu nursing progress note
resp:  present [** **] settings of c-pap 40% 5 peep and 18 pressure support with spont tvs of 350-450 and resp rate of 20-38.  suctioned frequently for a moderate amt of thick yellow and thin whitish sputum-many times suctioned after lavaging and bagging pt. occasional oral secretions with bile.  sputum for culture.  lung sounds coarse
intermittent cuff leaks.

cardiac:  nbp 100-124.58-62 with a pulse of 75-112 sr/st, infrequent pvcs.  K+ 4.7.  iv of d5ns infusing at 100cc/hr.  edematous lower extremities.  ca++ 8.5.

id:  98.1-98.4po.  contact precautions maintained.  wbc 7.7.  stool sent for c-diff and sputum sent for culture.

endo:  pt rec'd no insulin today as fs at 8a was 89 and at 5p 014.

gi:  abdomin initially was soft with + bowel sounds.  this afternoon more firm.  passed a large amt of liquidy brownish/black stool---ob +. started tube feeds of criticare via "j" portion of [** **] at 10cc/hr.  gastric portion of [** **] to low constant suction, with approx 500cc out in 12hrs.


Shift Events:
   -US of RUQ
   -Pan cultured
   -Dobhoff placed
 confirmed by CXR
 trophic TF restarted at 10ml/hr
   Sepsis, Severe (with organ dysfunction)
   Assessment:
   Patient spiked temperature to 101.6F.  Tachycardic, HR in 140
s.  BP
   low, 70
s.  CO increased from approx 6 to 8L/min.  SVV increased.
   Patient is auto-diuressing 200-400cc/hr, currently negative for the
   day.  Patient positive for gram negative rods in BAL.
   Action:
   Tylenol administered.  1.5L LR fluid bolus administered.  Neo drip
   re-initiated to maintain MAP > 65.  Albumin x1 administered.  Patient
   pan cultured
 urine, blood, and sputum.
   Vanco and Zosyn administered as ordered.
   Response:
   HR and BP responded positively to fluid, neo and albumin.  Cultures
   pending.  Low grade temp.
   Plan:
   Continue to monitor hemodynamics.  Titrate/wean neo as indicated.
   Follow up w/ pending cultures.  Monitor temperatue.  Administer abx for
   pna as ordered.  Follow [**Last Name (un) 3864**] numbers.
   Respiratory failure, acute (?  ARDS)
   Assessment:
   Patient orally intubated on CMV, 22 x 480, PEEP 12, 50%.  LS
   rhonchorous throughout.  Weak cough.  Sats 100%.
   Action:
   Decreased FiO2 to 40%, decreased PEEP to 10.  Pulmonary hygiene.  ABG


Mr. [**Known lastname **] is an 83M with a PMH s/f advanced dementia, and recurrent
   aspirations s/p PEG placement in [**2-/2195**] who presents from the [**Hospital **] after a suspected aspiration event.  He was in his USOH until
   this morning at 9AM, when he had an episode of yellow vomitus.  His
   exam at that time was notable for a firm and distended abdomen, for
   which a trial of laxatives were given, with little relief.  As day
   progressed, the patient began to develop respiratory distress, and
   developed a fever.  He was give Ceftriaxone 1 Gm IM x1, was suctioned
   and given neb treatments.  As his respiratory status continued to
   decline, he was brought to the ED--
MICU for further monitoring for
   Aspiration PNA ,UTI and SBO.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name **])
   Assessment:
   Found pt with 02 falling off into his mouth several times with 02 in
   high 90s. 02 removed with pt on rm air. Rr in upper 20s. Lungs with
   scattered rhonchi in upper lung fields with exp. wheezing at bases. Pt
   sounding
junky
 q1-2 hours.
   Action:
   Pt nt suctioned q1-2 hours for thick yellow secretions. Nebs given
   q6hours as ordered. Pt given iv zosyn for abx coverage of presumed
   aspiration pna.
   Response:
   Continues to require frequent nt suctioning but now on rm air with
   adequate o2 sats.
   Plan:
   Continue with aggressive pulm. Toilet, maintain asp. Precautions and
   hold tube feeds. f/u with culture data. Iv abx.
   Sepsis without organ dysfunction
   Assessment:
   Afebrile. Wbc 26.1 [**2-25**], am labs pending from [**2-26**]. bp stable. All
   culture data pending and source of sepsis is presumed by pna vs gi
   process. Surgery following for ? sbo. U.o. >30cc/hr . sbp in 100s-120s


EXERCISE MIBI                                                   Clip # [**Clip Number (Radiology) 20486**]
 Reason: CHEST PAIN.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Chest pain.

 SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:
 Exercise protocol:  Modified [**Doctor First Name 879**].
 Exercise duration:  6 minutes.
 Percent maximum predicted heart rate obtained:  43%.
 Symptoms during exercise:  none.
 Reason exercise terminated:  fatigue.
 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 26**]m sestamibi.
 There is soft tissue attenuation over the anterior wall  and apex.
 The study was interpreted using the 17-segment myocardial perfusion model.

 Left ventricular cavity size is normal.
 Stress perfusion images show mild reduction in tracer distribution involving the
 mid and distal anterior wall and the apex.  Rest perfusion images show this to
 be partially reversible.  That is, the abnormality is more prominent on the
 stress images when compared with the rest images.

 Gated images reveal normal wall motion.
 The calculated left ventricular ejection fraction is 64%.

 Compared with the prior study of [**2121-8-14**], the anterior wall and apical decrease
 in tracer activity is slightly more notable.


IMPRESSION:


1) Probably normal study with decreased activity in the anterior
 wall and apex, felt most likely due to soft tissue attenuation.  2) Normal
 ventricular cavity size and function.
 /nkg


         [**First Name4 (NamePattern1) 59**] [**Last Name (NamePattern1) 60**], M.D.
         [**Initials (NamePattern4) 61**] [**Last Name (NamePattern4) 62**] [**Last Name (NamePattern1) 63**], M.D.         Approved: FRI [**2126-1-11**] 12:00 PM
                                                   West [**Medical Record Number 20487**]


[**Name (NI) 761**] Care
Pt placed on nasal prong CPAP because of A&B spells. Pt's resp rates 30's to 60's. Pt nasally suctioned for a large amt of thick yellow secretions. Plan is to remain on nasal prong CPAP. Concider trial off later in the week.


Micu Nursing Progress Note:

Neuro: following commands. c/o pain r/t ett. Rec'd 2mg dilaudid x 2 for nursing care/am care.

CV: hemodynamically stable overnight. sbp 110-130. HR 80-90's. tmax 97.9po.  LLE ^^swelling >RRE. Upper extremeties with equal edema. Pulses dopplerable on RLE and bilat upper extremity. Difficulty dopplering LLE.
Results of US studies of upper extrem still pending

Resp: Rec'd on PSV 8 peep 5. fiO2 40%. TV's decreased slightly overnight and am abg more acidotic. PSV increased to 12. ABG to be done shortly. will decrease ps as tolerated. Moderate amts of yellow thick secretions. ETT tape changes and tube rotated. sl breakdown noted on L cheek. Increased drng from L nare(ngt site) ??sinusitus?? change to ogt??.

GI/GU: tf at goal nepro 35cc/h. Insulin gtt cont's however BS 88-114--->consider switching to nph and ssi.  Mushroom cath patent and draining brown liquid stool, large amts.    Urine bloody, with sm to moderate clots. Foley irrigated  x 5 times this shift. u/o poor 10-25cc/h --team aware.

Integ: jp drain cont's to drain ^^^amt of yellow liquid. vac dsg intact ->both dsg's to be changed by transplant team today. abd site to be cx'd again?

Social: family has expressed desire for family meeting. Sicu team aware and transplant informed last night----> coordinate time and day for meeting today if possible??


RESPIRATORY CARE NOTE
Baby [**Known lastname 4414**] remains on bubble CPAP 6 via Prongs FiO2 21-31%. Breath sounds are clear. Four brady's so far tonight, associated around feeds. Baby is on caffeine. RR 40-60's stable on CPAP cont to follow.


[**2152-10-7**] 11:26 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 44182**]
 Reason: eval for fluid overload, infiltrate
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


53 year old woman with liver failure, sepsis


REASON FOR THIS EXAMINATION:


eval for fluid overload, infiltrate
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Liver failure and sepsis.


TECHNIQUE:


Supine portable chest radiograph, single view.


COMPARISON:


CT abdomen and pelvis from an outside hospital done on [**10-7**], [**2152**].


FINDINGS:


There is moderate-sized left pleural effusion and adjacent left
 lower lobe opacity.  There are low lung volumes.  There is no pneumothorax.
 Hilar and cardiac silhouette within normal limits. Mediastinum apperas widened
 from superior margin to level of AP window.


IMPRESSION:


Moderate-sized left pleural effusion. Wide mediastinum on left,
 which could reflect medially loculated effusion but CT may be helpful to
 exclude mediastinal lymph node enlargement or mass. Recommendation discussed
 by phone with Dr. [**Last Name (STitle) 1021**] on [**2152-10-7**].


Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.


[**2191-4-14**] 2:47 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 74076**]
 Reason: pls evaluate for acute change
 Admitting Diagnosis: HEMOPTYSIS\BRONCHOSCOPY RIGID; W. ARGON PLASMA COAGULATION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


68 year old man with trach adm w/hypoxia.


REASON FOR THIS EXAMINATION:


pls evaluate for acute change
 ______________________________________________________________________________


FINAL REPORT


AP CHEST, 3:09 A.M., ON [**4-14**]


HISTORY:


Patient with tracheostomy admitted for hypoxia.


IMPRESSION:


AP chest compared to [**4-12**] and [**4-13**]:

 Severe pulmonary edema unchanged since [**4-13**], accompanied by increasing
 moderate-sized right pleural effusion.  Tracheostomy tube is in standard
 position, but leftward displacement of the trachea could be due to hematoma
 from a since removed right subclavian line.  Tip of the left subclavian line
 projects over the SVC.  No pneumothorax.  Heart size normal.  [**Last Name (NamePattern1) 30982**] was
 paged to discuss these findings at the time of dictation.


Admission Date:  [**2144-10-18**]              Discharge Date:   [**2144-11-2**]

Date of Birth:  [**2093-9-6**]             Sex:   M

Service: MEDICINE

Allergies:
Augmentin / Tetracycline / Adhesive Tape Wp / Latex / Iodine /
Demerol

Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive


Procedure:


Mechanical Ventillation and Extubation
Central line placement and removal


History of Present Illness:
51 y/o M with hx of DM, asthma, depression and CKD who presents
today with respiratory distress.  Starting three days prior to
admission, he was noting a very dry cough and having some
shortness of breath.  Was nauseated but no vomiting.  Also have
some mild diarrhea.  He was having increasing wheezing and using
his albuterol inhaler at home.  Also noted fevers, chillls and
sweats and had a fever up to 104 at home.  He was trying to keep
himself out of the hospital to make it a doctors [**Name5 (PTitle) 648**] on
the day after admission.  Some of his family also had
respiratory symptoms.

He has had asthma exaccerbations before, but has never needed to
be intubated.  He recently has a hernia repair.

In the ED, his initial vitals were 100.4, 90s on RA; RR 50, 98%
NRB.  He was treated with levofloxacin and cipro.  He was given
continuous nebs and IV steroids for asthma exaccerbation.  He
was transferred to the ICU on a face mask.

On arrival, he is feeling slightly better than when he first
presented.  He cannot speak in full sentences and is using his
accessory muscle to breath.  He is tachypneic and uncomfortable
and visibly diaphoretic drenching his gown.  He complains of RUQ
pain that started with these current respiratory symptoms.  His
hernia repair was on his L side.  He denies chest pain,
dizziness, nausea, dysuria.


Past Medical


History:


1. Depression
2. Non-Hodkins Lymphoma (angioimmunoblastic -> Rx w/ steroids
and fludarabine x 8 cycles; in remission)
3. Asthma (PF ~ 550)
4. Chronic renal insufficiency (baseline ~ 1.4)
5. EtOH abuse
6. Tobacco abuse
7. Osteoarthritis
8. COPD
9. Elective Hernia Repair

Social


History:


Married with 2 sons. Currently on disability. Previous 60pk/yr
smoker and EtOH abuser but since quit.  Previously worked in
laundry servies at a hotel.

Family


History:


Sister w/ diabetes and suicide. Mother w/ MI, DM, and cirrhosis.


Physical


Exam:


Exam on Admission to MICU:
General Appearance: Well nourished, Overweight / Obese, Anxious,
Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Paradoxical), (Breath Sounds:
Crackles : , Wheezes : , Rhonchorous: )
Abdominal: Soft, Bowel sounds present.

Exam on Transfer to the Medicine Floor:
VITALS: T: 98.4, BP 102/85, HR 67, RR 18, 97% on 2L.  FSBG 120.
Weight 86.7kg
GENERAL: Pleasant, well appearing, in NAD, hands with mild
tremor
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. [**1-23**] deltoid, 4-/5 triceps, [**2-23**] biceps,
4+/5 wrist extensors. [**1-23**] IP, 4+/5 Hamstring and Quardriceps,
[**3-24**] DF, PF and TE. 2+ reflexes, equal BL. Couldn't assess
coordination because patient does not have the strength to move
fingers between nose and examiner's finger, and does not have
the strength to do heel-to-shin. Moderate hand tremor.  Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant



Pertinent Results:
ADMISSION LABS:
[**2144-10-18**] 06:25PM   WBC-5.8 RBC-5.27 HGB-14.5 HCT-42.8 MCV-81*
MCH-27.5 MCHC-33.9 RDW-15.3
[**2144-10-18**] 06:25PM   NEUTS-84.7* LYMPHS-12.9* MONOS-1.5* EOS-0.3
BASOS-0.7
[**2144-10-18**] 06:25PM   PT-14.7* PTT-34.5 INR(PT)-1.3*
[**2144-10-18**] 06:25PM   ALT(SGPT)-48* AST(SGOT)-134* ALK PHOS-64 TOT
BILI-0.3
[**2144-10-18**] 06:25PM   LIPASE-152*
[**2144-10-18**] 06:25PM   GLUCOSE-150* UREA N-36* CREAT-2.7*
SODIUM-128* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-20* ANION
GAP-18
[**2144-10-18**] 06:44PM   LACTATE-1.6 K+-3.5
DISCHARGE LABS:
WBC 5.4 HCT 35.3 PLATELET 253
PT 14.4 PTT 32.7  INR 1.2
Creatinine 1.1
ALT 88 AST 27 LDH 212 CK 166 AP 59  Tbili 0.5
MICRO:
Influenza A/B DFA ([**2144-10-18**]):  POSITIVE FOR INFLUENZA A VIRAL
ANTIGEN.
.
Bronchial washings ([**2144-10-23**]):       KLEBSIELLA PNEUMONIAE
                             |
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
Sputum culture ([**2144-10-25**] and [**2144-10-26**]): KLEBSIELLA PNEUMONIAE.
Sensitivies as above.
.
Blood culture ([**2144-10-18**]): Neg
Blood culture ([**10-26**], [**10-28**]): NGTD
.
Urine culture ([**10-19**], [**10-24**], [**10-26**]): Neg
Urine culture ([**2144-10-31**]): Neg
.
C. Diff ([**2144-10-23**]): Neg
.
STUDIES:
RUQ US ([**2144-10-18**]):
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Cholelithiasis with no sign of cholecystitis.
3. Persistent right hydronephrosis.

CXR ([**2144-10-18**]):
Chronic blunting of the right costophrenic angle presumably due
to scarring and/or chronic effusion. No acute pulmonary process.

CXR ([**2144-10-21**]): The patient remains intubated. A right internal
central jugular venous catheter terminates at the cavoatrial
junction. A nasogastric tube again courses towards the stomach,
although its distal course is not well characterized.
The cardiac and mediastinal contours are unchanged. The lung
volumes are slightly increased, but in spite of increased lung
volumes, left perihilar and lower lobe opacities seem somewhat
more prominent, suggestive of worsening atelectasis or
pneumonia. Much or all of the left lower lobe is probably
involved. The presence of a coexisting right perihilar opacity
may be due to co-existing pulmonary vascular congestion.

CXR ([**2144-10-26**]): 1. Interval increase of left upper lobe opacity
2. Interval improvement of the left lower lobe opacity
3. Stable mild pulmonary edema.

CXR ([**2144-10-28**]): As compared to the previous examination, the
monitoring and support devices are unchanged. The pre-existing
predominantly left parenchymal opacities have clearly decreased
in extent. The size of the cardiac silhouette is unchanged. No
newly appeared focal parenchymal opacities suggesting pneumonia.

CXR ([**2144-10-29**]): As compared to the previous radiograph, the
endotracheal tube and the nasogastric tube has been removed. The
right-sided central venous access line is unchanged. Slight
increase in extent of a pre-existing right basal and
retrocardiac opacity. No other parenchymal opacities. Unchanged
size of the cardiac silhouette.

TTE ([**2144-10-20**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.


IMPRESSION:


Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Indeterminate pulmonary artery systolic pressures.
Compared with the report of the prior study (images unavailable
for review) of [**2132-6-3**], left ventricular hypertrophy is now
identified.


Brief Hospital Course:
51 y/o M with hx of asthma, CKD, DM, who presented with
respiratory distress.

# ACUTE RESPIRATORY DISTRESS SYNDROME: On arrival to MICU, he
appeared to be in respiratory distress, as he was his accessory
muscle to breath, was tachypneic and uncomfortable and  visibly
diaphoretic drenching his gown.  He was intubated shortly after
MICU admission.  The patient was found to be H1N1 positive and
also developed a severe asthma exacerbation. His chest x-ray was
initially normal, but developed bilateral pulmonary infiltrates
during his ICU admission.  He was treated with high-dose
osaltamavir for 10 days, continuous albuterol nebs, and
solumedrol followed by steroid taper.  He was initially very
hard to ventilate and had difficulty with sedation and was tried
on versed, fentanyl, propofol, and dilaudid.  Fentanyl was
stopped for concern of frozen chest and propofol was limited by
elevated triglycerides.  He was paralysed on [**10-20**] and a CVL was
placed.  He was maintained on intermittant paralytics until
[**10-24**].  He was extubated on [**10-28**]. His CVL was removed the same
day. On the day of discharge, patient was off oxygen, satting
well on room air.

# VENTILATOR-ASSOCIATED PNEUMONIA: On [**10-26**], he spiked fever to
101.2 and was started on cefepime/vanc. He developed
erythematous rash on face after cefepime and during vancomycin
infusion.  Antibiotic was changed to meropenem on [**10-27**].  Sputum
grew out klebsiella pneumoniae.  He was treated with meropenem
for 8 days ([**10-26**] to [**11-2**]). On the day of discharge on [**11-2**],
patient was afebrile, satting well on room air.  His lung exam
was clear to auscultation bilaterally.

# ACUTE ON CHRONIC RENAL FAILURE:  Patient was admitted with
acute on chronic renal failure, with FeNa 0.47.  His sodium was
initially 128, which improved with hydration.  After aggressive
rehydration his creatinine improved.  Following the peak of his
ARDS, he was diuresed with Lasix 20 mg [**Hospital1 **] until euvolemic.  He
did not require lasix after transfer to the floor.  Cr on
discharge was 1.1.  RUQ US showed persistent right
hydronephrosis, which could be related to his chronic renal
insufficiency.  He should have continued outpatient followup on
this right hydronephrosis.

# RIGHT UPPER QUADRANT PAIN:  He had RUQ pain on admission, and
an ultrasound showed echogenic liver consistent with fatty
infiltration, but other forms of liver disease and more advanced
liver disease including significant hepatic fibrosis/cirrhosis
cannot be excluded on this study.  He had elevated LFTs as well,
which were stable during this hospital stay.  This was possibly
related to influenza.  He should have follow up to confirm
resolution of these abnormalities.

# DIABETES: At home his blood sugars were well controlled on
glyburide.  However, in the MICU, his blood sugars were poorly
controlled on high-dose steroids.  He required an insulin drip
on [**10-23**].  Following cessation of IV steroids, he was weaned back
to an insulin sliding scale.  His glucose was well-controlled
after he was transferred to medicine floor.  He was discharged
home on glyburide.

# HYPERTENSION:  Patient was normotensive on admission, but
became hypertensive while not tolerating vent and as home BP
meds were held.  Around the time of extubation, he required a
labetalol drip for sytolics in the 200s.  He was well controlled
on his home regimen prior to discharge.

# STEROID-ASSOCIATED MYOPATHY: Patient developed marked muscle
weakness in MICU in the setting of paralytics and high dose
steroids. His CK peaked at 6958 on [**10-19**], which trended down
steadily as the dose of steroid was tapered down.  On the day of
discharge, his CK was within normal range, and he had regained
most of his strength.  He was evaluated by physical therapy and
was cleared for discharge home with home PT.  Patient finished
his steroid taper on the last day of this hospital stay.

# DEPRESSION: Outpatient amitriptyline and sertraline were
continued.

# PROPHYLAXIS: SQ hep, ompeprazole, bowel reg PRN
# FEN: regular diet per S&S.
# ACCESS: PIVs
# COMMUNICATION: with patient, daughter [**Name (NI) **] HCP [**Telephone/Fax (1) 13807**]
# CODE: full, confirmed


Medications on Admission:
Albuterol MDI
Amitriptyline 50 qHS
Zyrtec 10 mg daily
Diltiazem 180 mg ER daily
Advair 500-50mcg 1 puff [**Hospital1 **]
Glyburide 1.25 mg daily
Lisinopril 30 mg daily
Lorazepam 0.5 mg daily
Omeprazole 20 mg daily
Sertraline 200 mg daily
Zafirlukast [Accolate] 20 mg daily
ASA 81 mg daily

Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation once a day as needed for shortness of
breath or wheezing.
8. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO once a day.

12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.


Discharge Disposition:
Home With Service

Facility:
Nightingale Nursing

Discharge Diagnosis:
Primary diagnoses:
H1N1 pneumonia
ventilator-associated bacterial pneumonia

Secondary diagnoses:
Type II diabetes
COPD
Asthma
Hypertension
GERD
Depression


Discharge Condition:
Stable, afebrile, satting well on room air, regaining strength,
ambulating well with assistance


Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 1538**].
You were admitted to [**Hospital1 69**]
because of respiratory distress.  You were found to have H1N1
flu virus, and you had to be intubated in the intensive care
unit.  You were also found to have bacterial pneumonia, for
which you were treated with antibiotics.  You were extubated on
[**2144-10-28**], and since then you have been recovering
rapidly.  On discharge, you did not require oxygen, and your
lung exam sounds clear.

You developed significant weakness while you were in the
intensive care unit because of the medications you received.
You have been working with physical therapy daily, and are
regaining your strength nicely.  The physical therapist cleared
you to go home with visiting nurse service.

You were found to have slightly elevated liver function test
enzymes during this hospital stay.  Please follow up with your
primary care doctor on this.  Ultrasound of the abdomen also
showed that your right kidney has some distention from urine
(called "hydronephrosis"), please follow up with your primary
care doctor on this as well.

Please note that your medications have not been changed.  You
have finished the antibiotic course.

Please follow up with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]
below.

Followup Instructions:
We have made an [**Last Name (Titles) 648**] for you to see your primary care
doctor, Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] on Monday, [**2144-11-16**] at
10:00am.  Please call [**Telephone/Fax (1) 250**] if you have any questions.


Chief Complaint: Pneumonia, UTI
   24 Hour Events:
   Extubated, quite sedated, increased work of breathing, and new
   ventricular rhythm
   -Reintubated
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Vancomycin - [**2147-12-26**] 12:00 AM
   Meropenem - [**2147-12-26**] 06:40 AM
   Infusions:
   Propofol - 30 mcg/Kg/min
   Other ICU medications:
   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  [**2147-12-26**] 07:02 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.9
C (100.2
   Tcurrent: 36.7
C (98.1
   HR: 62 (61 - 85) bpm
   BP: 148/79(106) {97/64(78) - 171/97(127)} mmHg
   RR: 12 (12 - 23) insp/min
   SpO2: 99%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 78.9 kg (admission): 75.5 kg
   Height: 65 Inch
    CVP: 7 (0 - 19)mmHg
   Total In:
                                                                  1,999 mL
                                                                  1,128 mL
   PO:
   TF:
                                                                    450 mL
                                                                    282 mL
   IVF:
                                                                  1,309 mL
                                                                    566 mL
   Blood products:
   Total out:
                                                                  3,610 mL
                                                                    335 mL
   Urine:
                                                                  3,610 mL
                                                                    335 mL
   NG:
   Stool:


PATIENT/TEST INFORMATION:


Indication:


Shortness of breath.
Height: (in) 60
Weight (lb): 210
BSA (m2): 1.91 m2
BP (mm Hg): 119/60
HR (bpm): 70
Status: Inpatient
Date/Time: [**2202-9-23**] at 15:07
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


This study was compared to the prior study of [**2201-2-12**].


LEFT ATRIUM: Moderate LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.
No ASD by 2D or color Doppler.

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global
systolic function (LVEF>55%). No resting LVOT gradient. No VSD.

RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall
hypokinesis. Abnormal septal motion/position.

AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending
aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral
annular calcification. Mild thickening of mitral valve chordae. No MS.
Moderate (2+) MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate
[2+] TR. Moderate PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: No PS.

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium is moderately dilated. No atrial septal defect is seen by 2D
or color Doppler. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function (LVEF>55%). There is
no ventricular septal defect. The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2201-2-12**], RV systolic
function has decreased and the degree of pulmonary hypertension detected has
increased.


Pacemaker rhythm. Probable atrial sensed - ventricular paced rhythm. Compared
to the previous tracing no significant change.


[**2187-3-30**] Addendum:

BSat 6AM=43, given 1 amp D50 IV. Recheck BS at 645AM=154.


Case Management Note
I have confirmed that Care Group VNA will be able to see baby/family at home [**3-19**] between 3-4PM.  Page 1,2,3 will need to be faxed to [**Telephone/Fax (1) 1301**] [**3-19**].  [**Hospital1 272**] delivering home O2 & tube fdg supplies today.  Will follow.


Nursing Progress Note

5 BILI

1.  FEN  O/A  TF=150cc/kg/day Cals incr today to BM24.  Tol
feeds well, no spits, min asp thus far.  Belly soft, no
loops.  Voiding, stooling guiac neg.  P cont to assess FEN
needs, offer PO feeding as tol with [**Last Name (un) **].
2.  DEV  O/A  [**Known lastname 2591**] remains in an air isolette with stable
temp.  A/A with cares, irritable at times.  Loves pacifier,
however, occ'l desats with paci, see flowsheet.  P cont to
assess dev needs.
3.  [**Known lastname 2**]  O/A  Mom and [**Known lastname 45**] in for visit with inf's
brothers.  [**Name (NI) 521**] [**Name2 (NI) **] held [**Known lastname 2591**].  Updates given.  P cont
to support, educate.
See flowsheet for further details.

REVISIONS TO PATHWAY:

  5 BILI; d/c'd


NPN 7a-7p


#1: [**Known lastname 133**] conts on prong CPAP 5, FIO2 21-23%.  RR stable,
breathing with mild SC retractions.  BBScl/=.  Conts on
Caffiene as ordered.  No apnea/brady spells noted.  A:
stable on CPAP.  P:[**Known lastname **] to monitor resp status.  As
discussed in rounds will probably not trial off until next
week.  Caffiene dose adjusted for wt gains.

#3: TF: 150cc/k/d.  Conts on BM30 with Promod q4hrs gavaged
over 50mins.  Abd soft and full with +[**Last Name (un) 24**].  Ag 27-28cm.  No
loops.  [**Last Name (un) **] benign asps., no spits.  Strianing to stool,
rectal stim given x1, awaiting results.  Voiding qs.  A: [**Last Name (un) 62**]
feeds  P:[**Last Name (un) **] to monitor wt, exam and [**Last Name (un) 62**] to feeds.

#4: Swaddled infant and change to air mode this am.  Infant
initially got warm, needing isolette off for few hrs to
cool.  Temp now stable in 27.5 air isolette.  Alert and
active with cares, irritable at times.  Easily consoled with
pacifier and containment.  MAE.  Fonts soft/flat.  A: stable
P:[**Last Name (un) **] to monitor temp, and support dev needs.

#5: [**Last Name (un) **] in today, alternating cares.  Both updated.
Both participating in cares.  A: Involved [**Last Name (un) 4**]  P: [**Last Name (un) **]
to support and educate.

#9:  Hr stable.  Soft intermittent murmur noted.  Infant
with nml pulses and brisk refill.  BP stable.  A: stable
P:[**Last Name (un) **] to monitor.

#10: Temps stable.  Blood cultures remain negative to date.
Infant with appropriate behavior.  A: stable  P:[**Last Name (un) **] to
monitor.


[**2139-5-6**] 6:08 PM
 MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST                    Clip # [**Clip Number (Radiology) 12099**]
 Reason: Please also perform MRA. Please eval for evidence of stroke
 Admitting Diagnosis: SEIZURES
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


73 year old woman with history of strokes now with seizure


REASON FOR THIS EXAMINATION:


Please also perform MRA. Please eval for evidence of stroke or seizure focus.
 ______________________________________________________________________________


FINAL REPORT


ROUTINE MRI OF THE BRAIN WITHOUT GADOLINIUM.  ROUTINE MRA USING 3D TIME-OF-
 FLIGHT TECHNIQUE.

 Comparison is made with previous CTA performed five hours earlier, as well as
 an MRI from [**2137-10-21**].


FINDINGS:


No acute infarct is seen.  There are confluent periventricular and subcortical
 hyperintensities which likely reflect small vessel ischemic sequela.  Some of
 the lesions particularly in the bifrontal subcortical locations have increased
 in prominence since the prior study.  There is FLAIR sulcal hyperintensity
 which can be seen with leptomeningeal processes or high inspired FIO2.
 Clinical correlation is advised.

 Ventricles and sulci are stable in size.  MRA of the circle of [**Location (un) **]
 demonstrates patency of the anterior and posterior circulations.  There is a
 hypoplastic right distal vertebral artery.  No aneurysm or hemodynamically
 significant stenosis is seen within limits of this examination.

 There is slow flow in the right transverse sinus which is stable. Stable
 inflammatory changes of the mastoids bilaterally.


IMPRESSION:


No acute infarct.

 Subtle FLAIR sulcal hyperintensity, differential as discussed above.


NPN 11p-7a


#2 Received infant in 50cc of 100% FIO2 via NC. Attempted to
wean to 25cc but sats drifted. BBS clear and =. RR's
20-50's. Sats 96-97%. No bradys. A: comfortable in low flow
O2 P: support resp needs

#3 At 0100 care R arm noted to be considerably edematous. IV
[**Name6 (MD) **] and [**First Name9 (NamePattern2) 1**] [**Doctor Last Name 50**] and Dr. [**First Name (STitle) 325**] to bedside to evaluate.
Appearance of site as documented in above note by [**First Name (STitle) 1**].
Infant allowed to attempt ad lib feeds overnoc. Infant took
37cc of E20 at 0100,10cc at 0300 and 39cc at 0600. Abdominal
exam unremarkable. Dry diaper x 1. 13cc void x 1. No stool
passed overnoc.  A: po feeds improved P: Support nutritional
needs

#4 Temps stable on warmer. Waking for some feeds. Hypotonic.
Nested within high boundaries. Bottling skills improved-more
coordinated.  A: trisomy 21 P; Support developmental needs

#5 No parental contact thus far overnoc.


Demand pacing. Left axis deviation. Right bundle-branch block with left
anterior fascicular block. Anterior wall myocardial infarction - age
undetermined. Lateral ST-T wave changes are non-specific. Compared to the
previous tracing of [**2197-2-20**] no significant change.


TITLE:
   Chief Complaint: Fever, Altered Mental Status, Respiratory Distress
   24 Hour Events:
   - Neurology RECS: LP, EEG tomorrow, Narcan.
   - LP: Opening Pressure: 16 TP: 76 Glucose:80 WBC: 7 RBC: 1
   - Agitated overnight with survey xrays, moving all extremities, re
   sedated.
   - Aline placed.
   - Bronchoscopy Performed: Right Lower Lobe with purulent material
   - Bolused one liter to maintain MAP >60.
   Allergies:
   Penicillins
   Rash;
   Morphine
   anxiety
   diapho
   Last dose of Antibiotics:
   Ceftriaxone - [**2136-1-28**] 01:45 AM
   Acyclovir - [**2136-1-28**] 02:01 AM
   Metronidazole - [**2136-1-28**] 03:55 AM
   Infusions:
   Midazolam (Versed) - 2 mg/hour
   Fentanyl - 40 mcg/hour
   Other ICU medications:
   Midazolam (Versed) - [**2136-1-28**] 04:45 AM
   Fentanyl - [**2136-1-28**] 04:45 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  [**2136-1-28**] 06:44 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**38**] AM
   Tmax: 38.2
C (100.7
   Tcurrent: 37.3
C (99.2
   HR: 69 (69 - 119) bpm
   BP: 84/44(58) {84/44(58) - 137/75(98)} mmHg
   RR: 22 (10 - 27) insp/min
   SpO2: 97%
   Heart rhythm: SR (Sinus Rhythm)
             Total In:
                                                                  4,132 mL
                                                                  1,224 mL
   PO:
             TF:
   IVF:
                                                                  1,932 mL
                                                                    984 mL
   Blood products:
   Total out:
                                                                    575 mL
                                                                    525 mL
   Urine:
                                                                    275 mL
                                                                    525 mL
   NG:
   Stool:


[**Last Name (LF) 288**],[**First Name3 (LF) 289**] R.                   MED SICU-B                 [**2123-12-18**]  3:23 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 53629**]
 Reason: please eval for herniation, increased cerebral edema
 Admitting Diagnosis: MS CHANGE, DEHYDRATION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


53 year old man with recent pontine infarct, s/p LP with AMS and tachypnea


REASON FOR THIS EXAMINATION:


please eval for herniation, increased cerebral edema
 No contraindications for IV contrast
 ______________________________________________________________________________
                                  PFI REPORT
 1.  Hypodensity in the region of the right pons corresponding to area of
 infarct noted on prior MRI dated [**2123-12-12**].  No new areas of
 hypodensity identified.  If there is clinical concern for an acute ischemic
 process, an MRI may be obtained for further evaluation.

 These findings were communicated to Dr. [**Last Name (STitle) **] on [**2123-12-18**] at 6:30 p.m.


Admission Date:  [**2153-1-18**]              Discharge Date:   [**2153-1-20**]

Date of Birth:  [**2132-11-4**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Morphine

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Neck pain and hand weakness

Major Surgical or Invasive


Procedure:


Suboccipital craniotomy with C1 laminectomy and dural graft

History of Present Illness:
Pt is a 20-year-old woman who presents with weakness of her
hands bilaterally.  She has more significant symptoms in her
left upper extremity.  She has no difficulty with bowel,
bladder, or gait.  She was involved
in a motor vehicle accident in [**Month (only) **] after which she was
evaluated in [**Hospital1 **] Emergency Room.  She has no abnormal
sensation of temperature.  She does have some dysesthetic
symptoms in the left trapezius and right upper extremity.  She
has been wearing a soft collar and left arm sling, neither of
which has led to any meaningful improvement.


Past Medical


History:


Ankle surgery
gallbladder surgery

Social


History:


unknown

Family


History:


NC

Physical


Exam:


On examination, the left arm is in a sling and the patient is
somewhat uncooperative.  Nonetheless, we were able to
demonstrate
normal strength in the deltoid, biceps, and triceps bilaterally.

The hand intrinsics were clearly weak bilaterally.  Her lower
extremity strength was normal with the exception of the ankle
dorsiflexors, which were graded [**3-27**] bilaterally.  Sensory
examination showed patchy deficits in a nondermatomal pattern.
There was bilateral clonus.

ON discharge she is awake alert oriented.  She complains of pain
but wishes to be discharged.  She is not fully cooperative wiht
exam.

Her incision is clean and dry
Her motor exam is only limeited by her effort and does not
appear to have unilateral deficit.  She is [**3-27**] throughout her UE
exam and full on her lowers.  She does not have any clonus this
am.


Pertinent Results:
MRI of the cervical spine obtained on [**2152-12-8**]
demonstrates an extensive cervical syrinx.  It is quite large
and
the parenchyma of the spinal cord is extremely attenuated.
There
is evidence of a Chiari malformation with the descent of the
tonsils down to the level of C1.  There was no contrasted study.

[**2153-1-20**] 06:30AM BLOOD WBC-10.9 RBC-4.27 Hgb-12.4 Hct-37.2
MCV-87 MCH-29.0 MCHC-33.3 RDW-12.5 Plt Ct-211
[**2153-1-20**] 06:30AM BLOOD Plt Ct-211
[**2153-1-20**] 06:30AM BLOOD PT-12.7 PTT-26.7 INR(PT)-1.1
[**2153-1-20**] 06:30AM BLOOD Glucose-103* UreaN-7 Creat-0.9 Na-137
K-4.1 Cl-99 HCO3-29 AnGap-13
[**2153-1-20**] 06:30AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9

Brief Hospital Course:
Pt was admitted to neurosurgery for elective chiari
decompression with C1 laminectomy and dural graft. She tolerated
this procedure very well with no complications. Post operatively
she was transferred to the ICU for continued care including SBP
control and q1 neuro checks. She was started on a PCA for pain
control with good relif. Her post operative exam remained
unchanged and she still had some bilateral hand weakness 4+/5.
On the morning of [**1-19**] she was seen and was doing well. She was
transistioned to PO pain medications and sent to the floor in
stable condition. On the am of postop day #2 she was stable and
wishing to go home.  She is tolerating po intake, voiding
freely.  She was instructed that she not lie in bed all day at
home and that she needs to stay as active as possible.  Family
friend at the bedside in attendance.

Medications on Admission:
None

Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain: DO NOT DRIVE WHILE TAKING THIS MEDICATION.
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Chiari malformation
Cervical syrinx


Discharge Condition:
.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up/begin daily showers Post operative day #4
??????        No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
??????        Limit your use of stairs to 2-3 times per day
??????        Have a family member check your incision daily for
signs of infection
??????       you were given a soft cervical collar for comfort only,
wear cervical collar as instructed
??????        You may shower briefly without the collar
??????        Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
??????        Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
??????        Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
??????        Clearance to drive and return to work will be addressed
at your post-operative office visit

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????        Pain that is continually increasing or not relieved by
pain medicine
??????        Any weakness, numbness, tingling in your extremities
??????        Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
??????        Fever greater than or equal to 101?????? F
??????        Any change in your bowel or bladder habits




Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR
STAPLES

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.

YOU WILL NEED an MRI IN 6 WEEKS TO EVALUATE YOUR SYRINX



Completed by:[**2153-1-20**]


[**Last Name (LF) **],[**First Name3 (LF) **] C.                  CSURG CSRU                 [**2163-5-6**] 12:47 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 62117**]
 Reason: r/o inf, eff
 Admitting Diagnosis: AORTIC STENOSIS;CORONARY ARTERY DISEASE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


82 year old man with s/p avr/cabg


REASON FOR THIS EXAMINATION:


r/o inf, eff
 ______________________________________________________________________________
                                  PFI REPORT
 Nasogastric tube is installed, ending in the proximal stomach with its
 proximal sideholes at the gastroesophageal junction.  Increased left
 retrocardiac atelectasis.


Admission Date:  [**2105-11-21**]              Discharge Date:   [**2105-12-11**]

Date of Birth:  [**2053-3-9**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Seizure

Major Surgical or Invasive


Procedure:


None


History of Present Illness:
Mr. [**Known lastname 87792**] is a 52 year old gentleman with a pmh of DMII,
CRI, multiple neck abscesses, and traumatic brain injuries (SDH)
of unknown etiology who presents after a seizure and fall from
bed at his nursing home.
.
Mr [**Known lastname 87792**] is a Haitian earthquake survivor, who originally
presented to his dentist in [**Country 2045**] with a tooth abscess. He had
the wound opened and required skin grafting for healing. He was
found to have multiple abscesses in his neck.  The abscesses
were opened, and after the earthquake he was transferred to an
airport that had been set-up as a health care facility.  He
developed a stage IV decubitus ulcer on her coccyx as well as
around his penis from an indwelling catheter. He also was unable
to swallow so a PEG was placed.
.
He was transferred to [**Location (un) 2848**], for better care since [**Country 2045**] did not
have adequate resources.  He was stabilized and transferred to a
NH in the [**Location (un) 86**] area in [**Month (only) 205**]. He was progressing and improving,
however he had multiple falls that were not told to the family,
and he developed a foot drop on Friday.  In the past few weeks
he was more lethargic than usual. On [**11-20**] he was observed
having a tremor w/ teeth gringding, lasting several minutes.
When EMS arrived he was observed twisting on the right side. At
OSH he was loaded w/ dilantin, treated for hyperkalemia (5.9),
and treated w/ unasyn with concern for aspiration pneumonia.
When head CT and MRI showed small SAH (left parietal) and
subdural hematoma (left frontal, parietal, bilat occipital) he
was transferred to [**Hospital1 18**].


Past Medical


History:


DM type 2
CRI (w/ hx hyperkalemia)
anemia
s/p I and D of Left neck abscess
multiple UTI's
Decubitus ulcer
chronic brain injury of unknown nature
G-tube placement (for malnutrition)


Social


History:


Patient is a surviver of the Haitian earthquake, who was
transferred to [**Location (un) 2848**] for management of his multiple medical
problems. [**Name (NI) **] was living in a nursing home in Mass prior to
admission.

Family


History:


HTN, DMII

Physical


Exam:


Admission


Exam:


Vitals: T:97.9/97.7 BP:118/75 (108-124/58-86) P: 68 (68-76) R:16
O2:100% on RA
General: Alert,lying in bed in no acute distress, cacchectic
HEENT: Sclera anicteric
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Normal rate and regular rhythm, normal S1 + S2, II/VI SEM
murmur at the RUSB, no rubs or gallops
Abdomen: soft, non-tender, PEG tube in place with dressing C/D/I
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses in radials and DPs
bilaterally, no clubbing, cyanosis or edema
Skin:  warm, dry
Neuro: Moving all four extremities in bed, but unable to assess
strength this am


Pertinent Results:
[**2105-11-21**] 10:26PM BLOOD WBC-10.5 RBC-2.86* Hgb-8.6* Hct-25.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.7* Plt Ct-330
[**2105-11-21**] 10:26PM BLOOD PT-12.8 PTT-26.5 INR(PT)-1.1
[**2105-11-21**] 10:26PM BLOOD Plt Ct-330
[**2105-11-22**] 06:19AM BLOOD Ret Aut-0.7*
[**2105-11-21**] 10:26PM BLOOD Glucose-88 UreaN-43* Creat-2.0* Na-147*
K-4.3 Cl-113* HCO3-24 AnGap-14
[**2105-11-23**] 09:00AM BLOOD Glucose-124* UreaN-34* Creat-1.8* Na-142
K-4.8 Cl-112* HCO3-21* AnGap-14
[**2105-11-21**] 10:26PM BLOOD ALT-47* AST-32 LD(LDH)-209 AlkPhos-292*
TotBili-0.3
[**2105-12-10**] 05:55AM BLOOD ALT-85* AST-59* AlkPhos-329* TotBili-0.1
[**2105-11-22**] 06:19AM BLOOD CK(CPK)-136
[**2105-11-23**] 09:00AM BLOOD CK(CPK)-110
[**2105-11-21**] 10:26PM BLOOD cTropnT-0.19*
[**2105-11-22**] 06:19AM BLOOD CK-MB-6 cTropnT-0.17*
[**2105-11-23**] 09:00AM BLOOD CK-MB-4 cTropnT-0.15*
[**2105-11-22**] 06:19AM BLOOD calTIBC-203* Ferritn-573* TRF-156*
[**2105-11-22**] 06:39AM BLOOD %HbA1c-6.2* eAG-131*
[**2105-11-22**] 06:19AM BLOOD TSH-1.6
.
[**2105-12-8**] C. Diff toxin negative
.
Imaging:
NON-CONTRAST HEAD CT, WITH MULTIPLANAR REFORMATS.

There is hyperdense thickening of the falx to the left of
midline, compatible with a thin subdural hematoma, measuring no
more than 3 mm. Equivocal slightly larger idodense component is
also noted, measuring up to 4 mm (2a:22). There is no further
subdural collection identified. There is no subarachnoid,
intraparenchymal or intraventricular blood identified. There is
no parenchymal edema or mass effect. Ventricles and sulci are
prominent, compatible with atrophy, and there are
periventricular white matter hypodensities, compatible with
sequelae of chronic small vessel ischemic disease. The
[**Doctor Last Name 352**]-white matter differentiation is otherwise preserved,
without CT evidence of acute territorial infarction. The
visualized bones are free of fracture. There is scattered
opacification of the mastoid air cells, and mucosal thickening
in the left ethmoids. Remainder of the paranasal sinuses are
clear. The extracranial soft tissues, including the globes and
orbits, are unremarkable.


IMPRESSION:


1. Thickening of the falx, compatible with a subdural hematoma.
A thin
hyperdense component measures no more than 3 mm, with a possible
slightly
larger isodense component also noted, as above. No further
intracranial
hemorrhage is identified.

2. Global atrophy and sequelae of chronic small vessel ischemic
disease are noted.

Comparison with prior imaging reportedly performed at an outside
hospital
would be helpful for evaluation of stability of these findings.

EEG [**11-25**]:


IMPRESSION:


This in an abnormal continuous EEG due to the
presence of
frequent brief periods of rhythmic delta activity occurring
maximally
over the bifrontal regions seen more frequently during sleep.
This
pattern is most consistent with FIRDA which is consistent with a
mild
to moderate diffuse encephalopathy or a deep midline structural
defect.
However, given the reduction in frequency and duration of these
events
after the administration of antiepileptic medication yesterday,
these
events could also represent atypical frontal lobe seizures.

EEG [**11-26**]:


IMPRESSION:


This in an abnormal modified EEG telemetry due to
the
presence of frequent brief periods of rhythmic delta activity
occuring
maximally over the bifrontal regions. This pattern is most
consistent
with FIRDA which is consistent with a mild to moderate diffuse
encephalopathy or a deep midline structural defect. However,
these may
also represent atypical frontal lobe seizures. While a
comparison with
the previous tracing is limited given that the patient remains
mostly
awake, these periods of rhythmic delta activity appear to be
less
frequent than in the previous tracing.

Liver US [**12-8**]:


IMPRESSION:


No focal liver lesion or biliary dilatation seen.
Cholelithiasis
with no sign of cholecystitis. Scant trace of ascites.

CXR [**12-8**]:

SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal
contour is
normal. The heart is not enlarged. Lung volumes are somewhat
low,
accentuating perihilar vascular crowding. Left upper lobe
consolidation is
slightly more prominent. There is no pleural effusion. The bony
thorax is
unremarkable.


IMPRESSION:


Left upper lobe consolidation somewhat more
prominent

URINE CULTURE (Final [**2105-12-7**]):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |          PROTEUS MIRABILIS
                             |          |
AMPICILLIN------------              <=2 S
AMPICILLIN/SULBACTAM--  =>32 R      <=2 S
CEFAZOLIN-------------   <=4 S        8 S
CEFEPIME--------------   <=1 S      <=1 S
CEFTAZIDIME-----------   <=1 S      <=1 S
CEFTRIAXONE-----------   <=1 S      <=1 S
CIPROFLOXACIN---------   =>4 R        1 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
NITROFURANTOIN--------    64 I
PIPERACILLIN/TAZO-----    64 I      <=4 S
TOBRAMYCIN------------  =>16 R      <=1 S
TRIMETHOPRIM/SULFA----     2 S      <=1 S

[**2105-12-10**] 05:55AM BLOOD ALT-85* AST-59* AlkPhos-329* TotBili-0.1
[**2105-11-27**] 01:28PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
Lymphs-87 Monos-13
[**2105-11-27**] 01:28PM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-69
All CSF cultures were negative for growth and cytology did not
reveal any malignant cells

Brief Hospital Course:
52 year old gentleman with a pmh of DMII, CRI, multiple neck
abscesses, and traumatic brain injuries (SDH) of unknown
etiology who presents after a seizure and fall from bed at his
nursing home.

#Neuro/Mental status changes: Pt was intially admitted to
neurosurgery and it was felt that no surgical intervention was
indicated.  Serial head CTs showed stable SDHs.  Seizures were
thought most likely related to multiple SDH/trauma.  MRI was
obtained to evaluate vasculature for aneurysm given concern for
SAH on CT. Prior images were uploaded for comparison. Pt was
initially started on phenytoin 100mg TID for seizure ppx and
dose was later increased to 200mg PO TID after EEG raised
concern for frontal seizures. An MRI was performed to further
characterize ICH and the previously seen subtle signal
abnormality in the frontal cortical region on diffusion images
was confirmed to be artifactual.  Pt was found to have a
persistent encephalopathy and an LP was performed which was
negative (cultures, smear & cytology).  Pt has had an early
onset dementia of unclear etiology for the last year and MRI
showed global atrophy and ventricles enlarged out of proportion
to global atrophy.  Pt was evaluated for possible NPH, however a
large volume tap was unsuccessful.  In the setting of multiple
SDHs, UTI, seizures and renal insufficiency, neuro team
recommended that a dementia work up should be postponed until
medically stable and recovered from multiple SDHs.  Pt will
require cognitive neurology outpatient evaluation at [**Hospital1 18**],
number [**Telephone/Fax (1) 50382**].
.
# Acute Change in Mental Status: Pt was transfered to Medicine
around [**11-27**] at which time he was not responding to commands.
The patients Dilantin was titrated down and he was given 1pRBC
for persistent anemia.  Hypernatremia (hypovolemic in nature)
was corrected by increasing his free water boluses and IVF. Pt
was found to have a UTI that was treated with Ceftriaxone.
Encephalopathy improved after these interventions. Given the
persistent transaminitis on dilantin, pt was transitioned to
Keppra 500mg [**Hospital1 **] for seizure prophylaxis.  Pt was also started
on seroquel qhs for intermittent agitation and by the time of
discharge, he was responded to questions with one word answers,
naming common objects and tolerating some oral diet.

# Chronic renal insufficiency: Stable creatinine of 1.8-2.1
while an inpatient. Urine lytes showed a FeNa of 3.9%, suspected
to be from diabetic nephropathy, apparently diagnosed back in
[**Country 2045**].

# Anemia: Likely secondary to chronic renal insufficiency and
ACD. Iron level was normal, ferritin was high, TIBC was low.
Reticulocyte count was low.

# DMII: Newly diagnosed in [**Month (only) 956**] according to his sister. Hgb
A1c was 6.2.  Pt was on lantus and sliding scale insulin at
home. He had hypoglycemia while in house initially and as intake
improved, his blood sugars became more stable.

# Sacral decubitus ulcer stage II: This was noted on admission
and wound care was consulted.  Pt was treated with barrier
dressing, regular position changes and nutrition support with
TFs.  Ulcer was healing well.

# Iatrogenic hypospadias: Urology was consulted for urethral
erosion [**3-10**] chronic indwelling foley catheter, needed to heal
sacral decub ulcers (stage IV).  Family members, were [**Name2 (NI) 87793**]
about the procedure and decision to follow-up in [**Hospital 159**] clinic
to discuss the need for a suprapubic catheter (SPC) was made.
Given improved mental status in [**12-16**] and healing penile ulcer,
a voiding trial was attempted which was successful.  However, a
condom catheter was applied for incontinence and risk of
contaminating sacral decub.  Urology follow up was scheduled for
ongoing management of this issue.

# UTI: Urine Cx grew  Klebsiella resistant to Cipro/Unasy and
pansensitive Proteus mirabilis.  Pt. was treated with
ceftriaxone IV starting on [**2105-12-4**] and was written to complete
a 10 day course given the indwelling cath/condom cath.

# Transaminitis.  Mild on arrival w/ elevated AP and nl Bili.
RUQ US was negative, Hepatitis serologies were negative,
including Hep BsAb, for which he will require immunization.  Hep
C was negative.  Hep A Ab was positive. The LFT abnormalities
were thought possibly due to dilantin which was discontinued on
[**12-8**].   LFTs should be followed up on [**2105-12-21**].

# Hypothermia episode.  Pt. was triggered for an episode of
hypothermia to [**Age over 90 **]F and infectious w/u revealed an aspiration
PNA.  Pt was empirically treated with Ceftriaxone/Flagy (started
on [**2105-12-8**]), IVF and warming blanket.  Hemodynamics normalized
after 6 hrs of treatment and there were no further episodes of
hypothermia.  He was treated for presumed aspiration PNA x 7
days (last day [**2105-12-15**])

# Loose stools.  Onset after TF restarted.  C.Diff negative x 2
as were common stool cultures, O/P.  Amylase/Lipase were normal.
 Atrributed due to osmotic load from TF, may need readjustment
while at [**Hospital1 1501**].


Medications on Admission:
Omeprazole 20mg PO daily
Colace 100mg [**Hospital1 **] via G-tube
Lantus 8 units SC daily
Novolin R insulin sliding scale
Heparin 5000 units SC TID
Remeron 15mg PO QHS
Seroquel 75mg PO QHS

Discharge Medications:
1. Lantus
8 units injected subcutaneously once a day in the morning
2. Novolin R insulin
Please take according to your sliding scale
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day). 5000 units
4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. epoetin alfa 4,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
6. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime): give at 6pm daily please .
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for agitation.
8. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Day 1 = [**2105-12-8**], total of 8 days, last day
[**2105-12-15**].
10. ceftriaxone 1 gram Piggyback Sig: One (1) gram Intravenous
once a day for 3 days: Day 1 = [**12-4**]
Duration 10 days
Last day [**12-14**].
11. Outpatient Lab Work
Please perform CBC, Chem 7 and LFTs upon arrival.
Please recheck within one week prior to clinic appointments.
12. appointments
Please ensure patient follows up with appointments as listed
above, changed from discharge summary time of writing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]

Discharge Diagnosis:
Primary:
Seizure
Intracranial Bleed
Secondary:
Chronic renal insufficiency
Diabetes type 2
Anemia
Pre-existing decubitus and urethral ulcer


Discharge Condition:
Mental Status:

Alert, oriented to hospital and city at best, other times only
to name.  Able to perform DOW backwards at best, at other time
unable.
Names high frequency objects at best.  Follows 2 step commands
at best.  His mental status improves with family presence,
requires a translator for appropriate communication.

CNs: EOMi, PERRL, face symmeetric, tongue midline, palate
elevates symmetrically.

Motor: Increased tone in UEs, mild cogwheeling at b/l wrists and
biceps, mild spasticity as well.

Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Mr. [**Known lastname 87792**], it was a pleasure taking part in your care. You
were admitted to [**Hospital1 18**] because you had a seizure.  We did a CT
scan of your head which showed signs of a bleeding.  It was not
operable and remained stable throughout your hospital stay.
.
For seizures, you were evaluted by neurology and started on
medications to suppress seizures.

Because of the dilantin use (antiseizure medicine) you developed
abnormal liver enzymes.  Your seizure medicine was changed to
Keppra.

We had wound care evaluate your ulcers and they recommended
urology follow-up.
.
We made the following changes to your medications (please refer
to your discharge medication list for details).

You were discharged to a nursing home facility for further
rehabilitation and because you required 24 hr care.

Followup Instructions:
Please follow-up with your Nursing Home Care doctors

Please set-up an appointment with a primary care physician when
you leave your nursing home

Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2106-1-27**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: COGNITIVE NEUROLOGY UNIT
When: WEDNESDAY [**2106-1-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage Please ensure family
member is present for appointment.

Please follow up with the Liver Clinic on [**2106-1-26**] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] Liver Center, LMOB [**Location (un) **], Please call
([**Telephone/Fax (1) 1582**] to confirm the appointment.  Please ensure family
member is present for appointment.

Department: LIVER CENTER
When: TUESDAY [**2106-1-26**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2105-12-10**]


Neonatology note
20 d.o
on NC O2 25 cc, no spells.
2120 gm + 45
150 cc/kg/d with EBM 28 po/pg

[** 563**], pink
Clear lungs, mild retraction, mild periodic breathing
RR with soft systolic murmur
Abdomen soft

A: ex 31 [**5-18**] wks GA, AOP off caffeine, soft  heart murmur
P: HUS tomorrow, observe the respiratory status.


[**2139-8-3**] 3:20 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 75312**]
 Reason: ?interval change
 Admitting Diagnosis: CHF/HYPONATREMIA
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


50 year old man with increasing SOB x3 days, initial sats 58%.  Rales bilat


REASON FOR THIS EXAMINATION:


?interval change
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST RADIOGRAPH.


INDICATION:


CHF.

 Comparison to exams from the prior several days.


FINDINGS:


There is interval decrease in the amount of bibasilar air-space
 opacities extending to the hilar regions.  There is increased visualization of
 the right hemidiaphragm.  Apical lucencies are consistent with the patient's
 known emphysema.  There are no new areas of focal consolidation.  There is no
 pneumothorax.


IMPRESSION:


Improving CHF. Underlying emphysema.


Objective
   Height
   Admit weight
   Daily weight
   Weight change
   BMI
   173 cm
   74.2 kg
   71.7 kg ([**2177-1-13**] 12:00 AM)
   24.8
   Pertinent medications: Hypertonic saline @ 20mL/hr, ABx, heparin,
   lantus, RISS, Reglan, others noted
   Labs:
   Value
   Date
   Glucose
   79 mg/dL
   [**2177-1-13**] 02:03 AM
   Glucose Finger Stick
   167
   [**2177-1-12**] 10:00 PM
   BUN
   15 mg/dL
   [**2177-1-13**] 02:03 AM
   Creatinine
   0.6 mg/dL
   [**2177-1-13**] 02:03 AM
   Sodium
   139 mEq/L
   [**2177-1-13**] 02:03 AM
   Potassium
   4.0 mEq/L
   [**2177-1-13**] 02:03 AM
   Chloride
   104 mEq/L
   [**2177-1-13**] 02:03 AM
   TCO2
   25 mEq/L
   [**2177-1-13**] 02:03 AM
   PO2 (arterial)
   95.[**Numeric Identifier **] mm Hg
   [**2177-1-12**] 03:21 AM
   PCO2 (arterial)
   37 mm Hg
   [**2177-1-12**] 03:21 AM
   pH (arterial)
   7.49 units
   [**2177-1-12**] 03:21 AM
   pH (venous)
   7.46 units
   [**2177-1-3**] 06:39 AM
   pH (urine)
   5.0 units
   [**2177-1-12**] 10:37 PM
   CO2 (Calc) arterial
   29 mEq/L
   [**2177-1-12**] 03:21 AM
   Albumin
   3.4 g/dL
   [**2177-1-4**] 12:13 PM
   Calcium non-ionized
   8.0 mg/dL
   [**2177-1-13**] 02:03 AM
   Phosphorus
   4.3 mg/dL
   [**2177-1-13**] 02:03 AM
   Ionized Calcium
   1.14 mmol/L
   [**2177-1-9**] 02:08 AM
   Magnesium
   2.4 mg/dL
   [**2177-1-13**] 02:03 AM
   ALT
   126 IU/L
   [**2177-1-9**] 02:53 PM
   Alkaline Phosphate
   45 IU/L
   [**2177-1-2**] 04:33 AM
   AST
   94 IU/L
   [**2177-1-9**] 02:53 PM
   Total Bilirubin
   0.2 mg/dL
   [**2177-1-9**] 02:53 PM
   Phenytoin (Dilantin)
   1.3 ug/mL
   [**2177-1-10**] 02:50 AM
   WBC
   26.1 K/uL
   [**2177-1-13**] 02:03 AM
   Hgb
   9.9 g/dL
   [**2177-1-13**] 02:03 AM
   Hematocrit
   30.0 %
   [**2177-1-13**] 02:03 AM
   Current diet order / nutrition support: Tube Feeds: Boost Glucose
   Control @ 45ml/hr (1145kcals, 63g protein)
   GI: abd softly distended, bowel sounds present, brown liquid stool
   Assessment of Nutritional Status
   45 M adm with SAH and R intracerebellar hemorrhage, now s/p
   embolization of 1 branch for dural based AV fistula c/b rebleed now s/p
   craniectomy and clot evacuation.  Patient has been sedated on propofol,
   but is now off and team hopes to keep patient off sedation.  Tube feeds
   have been running at decreased rate all weekend to prevent overfeeding
   patient with calories from propofol.  Noted likely plan for trach and
   PEG later this week.
   Medical Nutrition Therapy Plan - Recommend the Following
          Tube feed goal for patient when off propofol is Boost
   Glucose Control @ 73mL/hr (1857kcals, 102g protein).
          This goal will be the same after PEG is placed.
          Following- #[**Numeric Identifier 977**]


[**2161-10-8**] 9:22 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 26**] # [**Clip Number (Radiology) 36785**]
 Reason: evaluate for new edema, cause for respiratory distress
 Admitting Diagnosis: ACUTE CORONARY SYNDROME
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


81 year old woman with dyspnea, with acute SOB, ?pulmonary edema


REASON FOR THIS EXAMINATION:


evaluate for new edema, cause for respiratory distress
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


New edema, cause for respiratory distress.

 CHEST, SINGLE AP VIEW. Supine positioning.

 Compared with earlier the same day, the cardiomediastinal silhouette is
 stable, with cardiomegaly and calcified aorta.  There is upper zone
 redistribution and diffuse vascular blurring, consistent with CHF.  There is
 left lower lobe collapse and/or consolidation and probable small left pleural
 effusion.  No gross right effusion is identified.

 Compared with [**2161-10-8**], CHF findings are slightly worse.  Otherwise, no
 significant change is detected.


[**2195-10-7**] 1:38 PM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 69477**]
 Reason: eval for effusion/ hemothorax
 Admitting Diagnosis: AORTIC STENOSIS\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


81 year old man s/p cabg with post op bleeding


REASON FOR THIS EXAMINATION:


eval for effusion/ hemothorax
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


81-year-old man status post CABG with postoperative bleeding.
 Evaluate for effusion versus hemothorax.


COMPARISON:


[**2195-10-5**] and [**2195-10-6**].


FINDINGS:


A small right and moderate-to-large left pleural effusion are
 unchanged since the prior exam yesterday.  Central pulmonary vascular
 congestion has significantly improved.  Sternotomy wires are intact and
 mediastinal clips are in unchanged position.  A right-sided internal jugular
 catheter tip remains in the low SVC.


IMPRESSION:


Stable small right and moderate-to-large left effusions.


NICU Attending Triage Note

Asked to see this baby in consultation with Dr. [**Last Name (STitle) 4426**] regarding perinatal risk factors for sepsis.

I agree with above interval hx, data, PEx, A/[**Name Initial (MD) **] [**Name8 (MD) **] [**First Name9 (NamePattern2) 63**] [**Doctor Last Name 64**]. This asx term infant has berinatal risk factors for sepsis, namely maternal fever to 100.4, ROM x > 24 hours. Adequate intrapartum antibiotic prophylaxis, GBS -. Pre/perinatal hx o/w unremarkable. ROS o/w noncontributory, PEx benign in details as documented above. CBC/diff and blood cx sent and pending. Will transfer to NN, treat with antibiotics only if lab results or clinical course concerning for sepsis.


Clinical Nutrition:
O:
34 [**12-2**] wks CGA, BB now on DoL #8
Wt: 1340g (+15)-(<10th%ile); currently 15g above birth wt.
LN: 40cm (<10th%ile)
HC: 28.75cm (~10th%ile)
Labs: noted
Dsticks: 96, 76 over the past 24hrs
Access: PICC
TF: 140 cc/kg/day
Nutrition: BM20 @ 10cc/kg & PN/IL ( D12.5, 2.5g% & IL)
Projected 24hr nutrition: ~97Kcals/kg & ~3.1 g/kg of protein
GI: benign

A/goals:
[**Known lastname **] was started on trophic feeds over the weekend, tolerating well thus far. Continues on PN & IL. Voiding & stooled (yesterday), belly is soft w/ +BS. Plan is to continue on w/ trophic feeds for another 24hrs. Maximizing PN daily, has reached goal Kcals/protein & lipid in his PN. Advancing dextrose conc. QD as tolerated. Dsticks & lytes are stable. HUS results reviewed w/ team. Suggest advance feeds by 10cc/kg QD initially & monitor tolerance closely. Will cont. to follow w/team & participate in nutrition plans.


Probable sinus tachycardia
Repolarization changes may be partly due to rate
Left ventricular hypertrophy with ST-T abnormalities
Since last ECG, Lateral ST-T changes are new


Nursing Note: 7pm - 7am
Resp- Maintained vented on Ac 40%x500x22 with peep 5, tol well, last abg 7.39/41/106, coarse bs bil, suctioned for thick whitish secretion Q3h.

N- Agitated at begining of shift, sedation restarted, fentanyl drip increased to 50mcg/o and versed on at .5mg/o. Move all ext, pupils equal and reactive, not following commands. soft wrist restraint off.

CV- Hr 70s A paced rhythm, freq runs of v-tach. Pt started on amio and lidocaine drip, both at .5mg/min. K+ and MG repletion done. Ectopy subsides after intervention. AM labs: LFTs more elevated, pt on lidocaine drip. PA line in with good waveform, pcwp 22, cvp 10. BP on the low side 89/42 - 128/56, neo drip increased to 1.75mcg/kg/min.

GI- +bs, abd soft, no stool. Tpn continues, fsbs at 0200 225, covered with 4u reg insulin sc. AMylase down to 88.

GU- Foley to cd, voided 20cc overnight brownish urine with sed. creat up to 3.6.

Heme- Hct 31 this am, no signs of bleeding.

Skin- Warm and dry, duoderm to coccyx intact.

Social- Family visit last eve and they were updated on her status.

Plan- Continue supportive therapy, wean off vent as tolerated. Follow-up with cardiology in regarrds to AICD battery replacement.


Subdural hemorrhage (SDH)
   Assessment:
          Pt nonresponsive. Right pupil nonreactive 5mm and Left pupil
   3mm and sluggish. Minimal corneal on Right and impaired on L.
          Posturing extending R>L
          Tele in afib 90
s. Temp 101.1. Tylenol changed to ATC on day
   shift
          Loose liquid BM x2 on day shift. Hold bowel regime
          Phos continues to be low 1.0.
          MRI completed on day shift
   Action:
   MRI completed
          mannitol wean
   Tylenol atc
   Response:
   [**Name8 (MD) 24**] NP from neurosurg who spoke with daughter [**Name (NI) 2476**] who is [**Name (NI) 3556**] low
   percentage that patient will wake up
   Daughter [**Name (NI) 2476**] with appropriate questions regarding plan of care and CMO
   status and how process would unfold
   Daughter [**Name (NI) 2476**] made patient DNR
   Plan:
   Plan for rest of family to be updated on patient
s poor clinical status
   and possibly have family meeting with covering MD [**Doctor Last Name **] who is on for MD
   [**Doctor Last Name **] thru Monday, daughter [**Name (NI) 2476**] to let nursing know if they would
   like a family meeting
   DNR
   Plan for CMO when family is comfortable with status change, until then-
   cont SBP <140, q1 neuro checks,  and full medical support
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 2**])
   Assessment:
          Received on CPAP 5/5 60%
          Suctioned for thick tan/blood tinged sputum moderate amts
          LSCTA in upper lobes and diminished at bases
          GPC growing in pre-lim cultures perfomed on mini BAL [**3-2**]
   Action:
          Suctioned PRN
          Became hypertensive w/ high MV and RR 28-35 w/ accessory
   muscle use. PSupp increased to 19
          Ceftriaxone and levofloxacin as ordered
          Oral care q4
   Response:
          Cont to have thick tan secretions
          Remains on cpap [**4-28**] 60%
   Plan:
          Awaiting final culture date on mini BAL from [**3-2**]
          Cont CTX and Levoflox as ordered


Nursing Discharge note:
Infant stable. Day [**5-25**] of spell count. Lungs clear and
equal. Soft murmur on lower sternal border. Cardiology seen
yesterday - called "innocent murmur". Follow at pedi. Pale
pink. well perfused. Ad lib demand feeding. Bottles well.
Well coordinated. PO's - 80-120cc's q 4hours. Abdomin soft
and round. Nontender. +BS. Voiding and stooling regularly.
Guiac pos stools. History of Milk protein allergy. To be
followed by pediatrian. Hopes to change to BM - mom on
lactose free diet.  Temps stable. Good tone. Waking for
feeds. Ready for discharge. VNA - due to visit [**Doctor First Name 125**]. Sunday.
Pedi appoint made for [**1-30**] at 1900pm.


[**2193-7-5**] 5:33 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 29607**]
 Reason: LLL INFILTRATE
 Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; MINIMALLY INVASIVE/SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


68 year old man with severe AS s/p AVR


REASON FOR THIS EXAMINATION:


? new infiltrate vs effusion
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


68 year old man with severe AS status post AVR.  ? new infiltrate
 or effusion.


COMPARISON:


[**2193-7-3**].

 CHEST AP:  The patient is status post median sternotomy and AVR.  ETT and PA
 catheter have been removed.  A right IJ sheath is in unchanged position.  The
 cardiac, mediastinal and hilar contours are stable in appearance.  There has
 been interval development of a left lower lobe consolidation which may
 represent atelectasis versus infiltrate.  A small left pleural effusion is now
 seen.  The right lung is clear.  Osseous and soft tissue structures are stable
 in appearance.


IMPRESSION:


Interval development of left lower lobe consolidation and pleural
 effusion.  Differential includes atelectasis versus pneumonia.


[**2179-2-4**] 7:10 AM
 MR HEAD W/O CONTRAST; MR-ANGIO HEAD                             Clip # [**Clip Number (Radiology) 65569**]
 Reason: 55 year old woman with NF and intracranial stenosis with lef
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


55 year old woman with above


REASON FOR THIS EXAMINATION:


55 year old woman with NF and intracranial stenosis with left sided sensory
  signs.
  Looking for progression of carotid
 ______________________________________________________________________________


FINAL REPORT


CLINICAL INFORMATION:  Neurofibromatosis, intracranial stenosis with left-
 sided sensory signs, ? progression.

 MRI OF BRAIN AND MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES:

 Exam is compared to prior studies of [**2178-5-27**] and [**2177-1-31**].


FINDINGS:


BRAIN:  There is no change from the previous examination. There is moderate
 prominence of ventricles and sulci consistent with moderate brain atrophy.
 There is no evidence of a focal mass or hemorrhage.  There is no evidence of a
 focal extraaxial lesion or fluid collection.  There is no evidence of a
 territorial infarct.


IMPRESSION:


Moderate brain atrophy.  No change from prior study.  No acute
 mass or hemorrhage.

 MRA:  Again is noted diffuse narrowing of the right internal carotid artery,
 including its vertical petrous portion.  This is especially true of the
 supracavenous, where is a more focal area of narrowing.  This is unchanged
 from previous exam of [**2177-1-31**].  The right A1 portion of the anterior cerebral
 artery is patent, as is the posterior communicating artery on both the right
 and left sides.  There is no evidence of aneurysm.


IMPRESSION:


Persistent supraclinoid stenosis on the right side, unchanged
 from prior study.


ECG interpreted by ordering physician.
[**Name10 (NameIs) 2**] see corresponding office note for interpretation.


[**2172-2-4**] 4:36 PM
 CT CHEST W/CONTRAST; CT ABDOMEN AND PELVIS W/CONTRAST W/ONC TABLESClip # [**Telephone/Fax (1) 29752**]
 Reason: tumor assessment prior to starting therapy
  Contrast: OMNIPAQUE Amt: 130
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


57 year old man with known metastatic melanoma


REASON FOR THIS EXAMINATION:


tumor assessment prior to starting therapy
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Melanoma, for followup.


TECHNIQUE:


Multidetector CT imaging was performed from the thoracic inlet
 through to the pubic symphysis during intravenous contrast administration.
 Sagittal and coronal reformatted images were generated.  Three-minute delayed
 imaging of the abdomen was also performed.

 CT OF THE CHEST,


FINDINGS:


Current study is compared to the most prior recent
 study, which is of [**2171-9-17**].  Again appreciated are numerous bilateral
 pulmonary metastases which appear grossly unchanged in size and number.  There
 is a prevascular node measuring 28.7 mm which is unchanged, there is also a
 second prevascular node (series 2, image 19), which is also unchanged in size.
 There is a large right ventricular mass identified, though difficult to
 quantify, there appears to be an overall decrease in size.  There is, however,
 a filling defect within the apex of the left ventricle, previously this could
 have been mistaken for papillary muscle, however, this has increased in size,
 before measuring 18.2 mm, now measuring 31.5 mm.  Additionally, within the
 right atrium at the SVC-atrial junction, there is a 7-mm hypodensity, this may
 represent a small adherent thrombus or metastatic focus, but is new.

 Coronary artery calcification, no pulmonary arterial filling defects, no
 subcutaneous nodules identified.  The patient is status post sternotomy.
 There is a node adjacent to the pericardium on the right (series 2, image 41),
 which is unchanged in size.

 CT OF THE ABDOMEN WITH CONTRAST,


FINDINGS:


Again appreciated are ill-defined
 densities scattered throughout the liver, very poorly characterized; however,
 not simple cysts and likely representing metastatic disease.  Overall size and
 number has not changed.  The portal vein is patent, the biliary tree is not
 dilated.  The gallbladder is grossly unremarkable.

 The spleen, adrenal glands, and pancreas appear normal.  Simple cysts
 involving the right kidney, the left kidney shows an area of cortical loss
 involving the inferior pole, likely due to a prior inflammatory process and
 unchanged.  No hydronephrosis, no definite renal involvement by this patient's
 melanoma.  There is no retroperitoneal adenopathy, no free fluid.  There are
 scattered non-pathologically enlarged mesenteric lymph nodes.

 There is an intussusception of small bowel which appears uncomplicated (series
 2, image 77), which is resolved on the delayed imaging.  Transient
 intussusception can be seen normally; however, attention to this area on
                                                             (Over)

 [**2172-2-4**] 4:36 PM
 CT CHEST W/CONTRAST; CT ABDOMEN AND PELVIS W/CONTRAST W/ONC TABLESClip # [**Telephone/Fax (1) 29752**]
 Reason: tumor assessment prior to starting therapy
  Contrast: OMNIPAQUE Amt: 130
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 followup as this may indicate an unseen possible small bowel metastatic focus.
 Midline small bowel anastomosis is again identified and unchanged.

 CT OF THE PELVIS WITH CONTRAST,


FINDINGS:


There is no free fluid, visualized
 loops of large and small bowel appear unremarkable.  The bladder is normal in
 appearance.  There is a single enhancing lymph node within the right inguinal
 area, this is unchanged in size, enhancement suggests that this is active
 disease.  There is a small subcutaneous nodule on the left with some
 enhancement, this appears new compared to the prior exam and measures 12.1 mm.

 Bone windows demonstrate diffuse metastatic involvement including areas of
 bony destruction, most marked in the right iliac bone.  Findings are
 unchanged, however.


IMPRESSION:


Compared to the exam of [**2171-9-17**]:
 1.  No change in multiple bilateral pulmonary mets and mediastinal adenopathy.
 Qualitative decrease in right ventricular metastatic focus; however, there is
 a left ventricular metastatic focus.  Additionally, a single filling defect
 within the SVC-right atrial junction, which may represent metastatic disease
 or a focal adherent thrombus.

 2.  No change in diffuse hepatic hypodensities, not well characterized but
 suspicious for metastatic disease.

 3.  Transient small bowel intussusception which is resolved on delayed
 imaging.  No definite lead point; however, attention to this area on followup
 as melanoma may metastasize to small bowel.

 4.  Small mesenteric nodes, none pathologically enlarged, unchanged in size
 and number compared to the prior exam.

 5.  Right-sided inguinal adenopathy with enhancement, consistent with active
 disease, new subcutaneous soft tissue mass within the left anterior abdominal
 wall (series 2, image 114), consistent with a metastatic focus.

 6.  Multiple bony mets unchanged.


Resp. Note
Remains intubated on vent PSV/CPAP-5/5/40%. TVs 700-800cc with RR teens to low twenties. Receiving ventolin MDIs Q4. Will cont to support.


[**2117-10-11**] 8:23 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 21802**]
 Reason: eval PNA
 Admitting Diagnosis: CARDIAC ARREST
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


71 y/o M with severe COPD s/p respiratory s/p intubation with high ETT


REASON FOR THIS EXAMINATION:


eval PNA
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Severe COPD, respiratory distress, endotracheal tube placement.

 PORTABLE AP CHEST:  Comparison is made to the study from [**2117-10-10**].
 Again seen is an endotracheal tube in satisfactory position in the mid-
 trachea, a right internal jugular central venous line with the tip in the
 distal SVC, and an NG tube with the tip not visualized, off the inferior film
 edge.  The cardiac size is stable.  There is continued pulmonary edema in both
 lungs, consistent with congestive heart failure.  There are stable bibasilar
 parenchymal opacities.  Compared to the prior study, the appearance is
 unchanged.


IMPRESSION:


Stable radiographic appearance of the chest.


npn 1900-0700


2: fen
current weight 1830gms up 45gms. total fluids remain at
150cc/kilo/day of pe 26 with promod. infant getting all
feeds gavaged at this time. plan to hold attempting po feeds

for 24 hours. infant has had one small and one med spit thus
far this shift. increased time of gavage feeding. infant abd
exam benign. no loops. girths stable. voiding and stooling.


3: g/d
temps stable in an open crib. alert and active with cares.
sleeps well inbetween. sucks on pacifier. brings hands to
face. aga. continue to monitor for developmental milestones.


4: resp
remains in ra. no spells. rr 40-60's. no spells and no dsats
thus far this shift. lung sounds clear and equal. mild
subcostal/intercostal retractions. no increased wob noted.
continue to monitor for changes in resp status.

5: parenting
no contact from [**Name2 (NI) **] thus far this shift.


NPN  1900-0700
Neuro:  Sedated on versed 1mg/hr and Fent 20mcg/hr, pt light, opens eyes & follows commands, no movement on R side s/p CVA, moves L extrem in bed.  Denies pain.  1mg versed bolus few times p suctioning.

CV:  Hemodyn stable.  ST, low 100s.  PP by doppler. Tmax 100.1 po.

Resp:  On PSV ~ 24 hrs at 5/15/40%, tol well w RR 14-19, sats 100.  Cont to require freq sx  ~q1hr for mod thick, yellow secretions, sometimes frothy.  Less oral secretions.  LS coarse t/o, freq rhonchorus prior to sx, then clearing.  Rsbi in am.

GI:  Hypoactive BS, abd soft distended, firmer on L side, team examined, aware of sl tenderness.  TF tol well w max residual 10cc (previous noc 150cc).  24 hrs ago had # of soft stools, but due to distension pt given senna, only smears since then.  Stool tarry green, OB neg.

endo:  FS >200, [**Month (only) 83**] NEED ^ tighter SS.  Received glargine.

GU:  [**Name (NI) **], pt fld bal neg 430mls last 24 hrs, cr decreasing.

Skin:  L [**Name (NI) 4164**] ulcer, black, no change.

Social:  Daughter called and updated.

Plan:  F/u on am labs, replete lytes as needed. Cont to wean vent as tol.


TITLE:
   62 yo female w hx of lt ankle surgery  developed abd pain in rehab on
   [**10-11**]. Adm to [**Hospital1 **] CT + free air abd. Underwent exp lap , hemicolectomy
   (perforated cecum) & rt salpingoopherectomy.
   [**Last Name 19**] Problem
 [**Name (NI) **] onset Abdominal pain, abd distention, + free air in
   abdomen/liver region
   Assessment:
   Adm from [**Hospital Ward Name 408**] 9 Awake, alert, oriented x3 . [**Last Name (un) **] 120
s to 130  sbp
   110-130
s T 100.2 orally. O2 sat 98-100% on rm air initially. c/o of
   [**7-30**] abd pain. Abd firm, distended tender, hypoactive bowel sounds,
   lower portion of abd wound open and packed w ns gauze dsd dry/intact.
   Abd binder in place. Ngt clamped. Foley to gd w clear yellow urine
   small amts. 22 gauge lt wrist.. Lt leg cast to mid calf, cap refill
   toes wnl. Rt dp/pt palp.
   Action:
   Ngt to lws draining milky white->green drainage. IV access ?. Iv
   infiltrated and IV therapy placed 22ga iv lt hand. Rt radial art line
   placed by Dr [**Last Name (STitle) 823**]. Labs sent w Type and X match. Medicated w
   dilaudid 1mg iv for [**7-30**] abd pain. LR infusing at 125cc/hr -Iv flagyl
   infusing after cipro completed. Attempted additional iv access for fld
   resusc unsuccessful. Pt to go to OR tonoc for exp lap per HO and
   receive central line access. Anesthesia and OR consents completed. Pt
   declined to have next of [**Doctor First Name **] phoned at this time.
   Response:
   Some pain relief [**2152-4-24**] pain after dilaudid.  Systolic bp remained
   stable despite tachycardia and low grade temps.
   Plan:
   Placed on transport monitor and sent to OR at 0055 with stable bp and
   [**Last Name (un) **] 130 . Face mask O2 at 8-10 lpm w O2 sat at 100%.


npn 1900-0700


#2 resp
O: pt in r/a with rr 30-50's. lsc and equal. mild sc
retractions noted. no spells thus far this shift. a; stable
p: continue to monitor for changes and support.
#3 fen
O: tf 150cc/kg of bm26 or pe26 gavaged q3hours. wt. 1.715kg
(-5gms). abd benign full and round at one point. ag 23-25cm.
voiding and stooling yellow guiac neg stools. no spits. max
aspirate of 5cc partially digested milk. dstics stable 54,
85. p; will repeat one more dstic this am. tolerating
feedings well.
#4 [** **]
no contact with [**Name2 (NI) **] thus far this shift.
#5 hyperbili
to recheck bili this am, see flow sheet for results.
#6 g&d
o: pt in open crib with low temps 97.5-97.9. warming lights
applied for short time and temps stable since. alert and
awake with cares, quiet. fontanelles soft and flat. sucking
on binki. maew. a: stable p: continue to monitor for cares
and support as needed.


NURSING NOTE 0700HRS - 1600HRS

ADMIT TO MICU A @ 12MD WITH LOWER G/I BLEED


NEURO - ALERT/ORIENTATE X3 ON ADMISSION, MOVING ALL 4 LIMBS/FULL POWER - PUPILS EQUAL /REACTIVE - NO COMPLAINTS OF [**Last Name (un) 255**] PAIN SINCE ADMISSION - DID RECEIVE ATIVAN/FENTANYL FOR SEDATION FOR ENDOSCOPY SLEEPY BUT EASILY ROUSABLE POST AND ORIENTATED


RESP - LUNGS CLEAR SATS 100% ON 2L VIA N/C RR 12-15


CVS - B/P STABLE THROUGOUT 90-120 SYSTOLIC SINUS RHYTM/TACH 80-110  - FEBRILE @ 100.4 ON ADMISSION RECEIVED ACETAMINOPHEN PRIOR TO BLOOD TRANSFUSSION AFEBRILE SINCE - HAS RECEIVED X5 UNITS OF BLOOD FOR A TOTAL OF 6 THEN TO RECEIVE FFP/PLATLETS - HCT DROPPED TO 18 THIS AM POST BLOOD RAISED TO 26 - ALSO RECEIVED VIT K 1MG - FOR REPEAT BLOODS THIS EVE/POST TRANSFUSSIONS

G/I - PATIENT HAD RED TAG CELL PROCEDURE @ NUCLEAR MEDICINE IDENTIFYING BLEED - ENDOSCOPY PERFORMED ON THE UNIT SHOWING BLEEDING OF LOWER G/I TRACT BUT UNABLE TO IDENTIFY BLEEDING POINT , THEREFORE TO GO TO IR FOR FURTHER INVESTIGATION -   X1 EPISODE OF MALEANA SINCE
 ADMISSION APPROX 200CC - BOWELS SOUNDS PRESENT

G/U - NOT CATHERTERISED AT PRESENT - HAS PASSED URINE X2 IN NUCLEAR MEDICINE X1 SINCE ADMISSION TO UNIT

LINES - X2 PERIPHERAL INSITU ATTEMPTED FURTHER ACCESS BUT UNSSUCCESSFUL ? FOR CENTRAL LINE

SKIN - INTACT

SOCIAL - POWER OF ATTORNEY IS FRIEND MARK WHO LIVES OUT OF STATE BUT FRIEND CALLED [**Name (NI) **] IS LOCAL AND [**Month (only) **] BE CONTACT[**Name (NI) **]


Admission Date:  [**2180-2-3**]              Discharge Date:   [**2180-2-18**]

Date of Birth:  [**2158-7-17**]             Sex:   F

Service: PLASTIC

Allergies:
Aspirin

Attending:[**First Name3 (LF) 7733**]
Chief Complaint:
1.  Longitudinal deficiency radius, radial club hand left.
2.  Camptodactyly, PIP flexion contractures, left long, ring and
fifth fingers.
3.  Congenital absence of thumb left.
4.  Status post first angle distraction lengthening process.


Major Surgical or Invasive


Procedure:


1.  Removal of distraction apparatus, left forearm and hand.
2.  Scar revision, pin hole tracts ulnar aspect left hand.
3.  Pre vascularized fibular transfer from right leg and left
    forearm.
4.  Plastic closure left leg (35.0 cm).
5.  Application of short posterior splint right leg.
6.  Application of VAC dressing left forearm.
7.  C wire fixation of left long, ring and small digits.
8.  Application of posterior splint, left arm, elbow and
    forearm.
9.  Status post skin graft to left forearm


History of Present Illness:
21 yo F born with radial deficiencies involving both of her
upper extremities. Her left upper extremity was more severely
affected with complete absence of the
radius.  She underwent surgical stabilization of the floating
thumb on the right hand and a formal centralization of the left
carpus and hand in [**Country 532**]. On her initial visit, the patient had
a very small forearm and she elected to undergo distraction
lengthening, which resulted in approximately 122mm increased
lenth over the past 2-3 months.  She presents now for removal of
the distraction apparatus and transplantation of a vascularized
fibular graft into her left forearm.

Past Medical


History:


1.  Longitudinal deficiency radius, radial club hand left.
2.  Camptodactyly, PIP flexion contractures, left long, ring and
fifth fingers.
3.  Congenital absence of thumb left.
4.  Status post first angle distraction lengthening process.


Social


History:


Student at [**Location (un) 51954**] College, [**Location (un) 51954**] [**State 3914**]

Family


History:


NC

Physical


Exam:


VS: Tm 100.2 Tc 97.0 HR 97 BP 110/62 18 sat 99%ra.
Gen: AAOx3, NAD
Heart: RRR
Lungs: CTAB
Extr: LUE: surgical site looks good, no erythema, drainage;
xeroform applied; fingers warm, well-perfused, sensation/motor
intact
RLE: cast intact, toes warm, well-perfused, sensation/motor
intact
Neuro: grossly intact.

Pertinent Results:
[**2180-2-8**] WBC-8.2 RBC-2.90* Hgb-8.1* Hct-24.1* Plt Ct-352
[**2180-2-6**] WBC-11.8* RBC-3.10* Hgb-8.9* Hct-25.6* Plt Ct-303
[**2180-2-5**] WBC-14.9* RBC-3.07* Hgb-8.9* Hct-25.2* Plt Ct-258
[**2180-2-4**] WBC-14.2* RBC-3.11*# Hgb-9.0*# Hct-25.8*# Plt Ct-237

[**2180-2-5**] PT-12.8 PTT-27.4 INR(PT)-1.1
[**2180-2-4**] PT-13.6* PTT-29.4 INR(PT)-1.2*

[**2180-2-8**] Glucose-90 UreaN-8 Creat-0.5 Na-138 K-4.2 Cl-102
HCO3-29
[**2180-2-6**] Glucose-109* UreaN-5* Creat-0.5 Na-138 K-4.5 Cl-104
HCO3-29
[**2180-2-5**] Glucose-110* UreaN-3* Creat-0.4 Na-138 K-4.4 Cl-105
HCO3-28
[**2180-2-4**] Glucose-176* UreaN-5* Creat-0.5 Na-140 K-3.9 Cl-107
HCO3-25

[**2180-2-8**] Calcium-8.4 Phos-3.4 Mg-2.1
[**2180-2-6**] Calcium-8.3* Phos-2.5* Mg-1.9
[**2180-2-5**] Calcium-8.1* Phos-2.2* Mg-2.1
[**2180-2-4**] Calcium-7.3* Phos-3.0 Mg-1.4*

IMAGING:

CHEST (PORTABLE AP) IN O.R.  [**2180-2-3**] 7:05 PM


INDICATION:


Evaluate line placement.
COMPARISONS: None.
SUPINE AP CHEST: The tip of a right IJ central venous catheter
terminates in the right atrium. The tip of an endotracheal tube
terminates 6.5 cm above the level of the carina. Heart size is
normal. Widened appearance of the mediastinum is likely
secondary to supine position and AP technique. The lungs are
clear. There are no pleural effusions or pneumothoraces. The
visualized osseous structures are grossly unremarkable. Lung
volumes are low.


IMPRESSION:


Right IJ central venous catheter terminating in the
mid right atrium. No pneumothorax.
Findings were discussed with Dr. [**First Name (STitle) **] at 8 p.m. on [**2-2**], [**2179**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: [**Doctor First Name **] [**2180-2-3**] 9:48 PM


CHEST PORT. LINE PLACEMENT  [**2180-2-3**] 7:56 PM
[**Hospital 93**]


MEDICAL CONDITION:


21 year old woman with intubated


REASON FOR THIS EXAMINATION:


eval line placmeent


COMPARISON:


Comparison is made to prior study of earlier the
same day at 19:05 hours.
AP SEMI-UPRIGHT CHEST: The right internal jugular central venous
catheter has been pulled back with the tip terminating in the
distal SVC. The ET tube terminates 5.6 cm above the level of the
carina. Patient is rotated to the right. There are low lung
volumes. No pulmonary parenchymal consolidations are identified.
There are no pleural effusions or pneumothoraces.


IMPRESSION:


1. Right internal jugular central venous catheter terminating in
the distal SVC.
2. No pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: FRI [**2180-2-4**] 8:51 AM

CHEST (PORTABLE AP)  [**2180-2-4**] 5:17 AM
[**Hospital 93**]


MEDICAL CONDITION:


21 year old woman w/ tachycardia
REASON FOR


EXAMINATION:


Evaluation of a patient with
tachycardia.
Portable AP chest radiograph compared to [**2-2**], done at
20:00 p.m.
The right internal jugular line tip terminates at the junction
of internal jugular and subclavian vein.
The heart size is unchanged. The mediastinal contours are
unremarkable. The left lower lobe consolidation is slightly
increased compared to the previous film. No sizeable pleural
effusion is identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: FRI [**2180-2-4**] 7:39 PM

CHEST (PORTABLE AP)  [**2180-2-6**] 8:59 AM
[**Hospital 93**]


MEDICAL CONDITION:


21 year old woman s/p free fibula to left forearm w/ fever 101.5


REASON FOR THIS EXAMINATION:


r/o pneumonia


HISTORY:


Fever.
Single portable radiograph of the chest demonstrates normal
cardiomediastinal contour. There is evidence of left-sided
volume loss and left apical pleural thickening. No effusion. The
lungs are clear. Trachea is midline. Right internal jugular
central venous catheter is present with its tip in the SVC.


IMPRESSION:


No acute cardiopulmonary disease.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: SUN [**2180-2-6**] 1:11 PM

OPERATIVE REPORT
Name:  [**Known lastname 51955**], [**Known firstname 51956**]        Unit No:  [**Numeric Identifier 51957**]
Service:  PSU                     Date:  [**2180-2-3**]
Date of Birth:  [**2158-7-17**]        Sex:  F
Surgeon:  [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**]
ASSISTANT:  Dr. [**First Name (STitle) **]; Dr. [**Last Name (STitle) 23606**]; Dr. [**First Name (STitle) **]; Dr. [**Last Name (un) 51958**]
PREOPERATIVE DIAGNOSIS:
1.  Longitudinal deficiency radius, radial club hand left.
2.  Camptodactyly, PIP flexion contractures, left long, ring
    and fifth fingers.
3.  Congenital absence of thumb left.
4.  Status post first angle distraction lengthening process.

POSTOPERATIVE DIAGNOSIS:
1.  Longitudinal deficiency radius, radial club hand left.
2.  Camptodactyly, PIP flexion contractures, left long, ring
    and fifth fingers.
3.  Congenital absence of thumb left.
4.  Status post first angle distraction lengthening process.

OPERATION PERFORMED:
1.  Removal of distraction apparatus, left forearm and hand.
2.  Scar revision, pin hole tracts ulnar aspect left hand.
3.  Pre vascularized fibular transfer from right leg and left
    forearm.
4.  Plastic closure left leg (35.0 cm).
5.  Application of short posterior splint right leg.
6.  Application of VAC dressing right forearm.
7.  C wire fixation of left long, ring and small digits.
8.  Application of posterior splint, left arm, elbow and
    forearm.

ANESTHESIA:  General endotracheal.

HISTORICAL NOTE:  [**Known firstname **] is a young, college student in her
early 20s, presently on leave from [**Location (un) 51959**]in
[**Location (un) 51954**], [**State 3914**]. She has immigrated with her family from
[**Country 532**], where she was born with radial deficiencies involving
both of her upper extremities. Left upper extremity was more
severely affected and here, she had a complete absence of the
radius. Surgery done in [**Country 532**] was stabilization of the
floating thumb on the right hand and a formal centralization
of the left carpus and hand. When she was first seen, she had
a very small forearm. She elected distraction lengthening and
over the past 2-3 months, has been lengthened approximately
122 mm. She is brought to the operating room today for
removal of the distraction apparatus and insertion of a
vascularized fibular graft into the intercalated gap.

DESCRIPTION OF


PROCEDURE:


With the patient on the operating
table in the supine position, with the head of the bed
elevated 10 degrees, general endotracheal anesthetic was
induced without difficulty. Due to the large unusual size of
her body and large size of her breasts, she was positioned
almost in the right lateral decubitus position with the right
leg pronated as much as possible for the fibular dissection.
Tourniquet was wrapped at the left upper humeral level for
dissection in the forearm and hand. Left arm was on an arm
board. After all of the appropriate monitoring lines, IV
lines, etc. Were placed, dissection started on the leg.

The leg was elevated, exsanguinated and the tourniquet at the
mid thigh level was inflated to 350 mmHg. The usual incision
was made along the line between the lateral malleolus and the
fibular head proximally. Only one large perforator was
identified by Doppler examination intraoperatively before the
incision was made. The dissection progressed through skin and
large layer of subcutaneous fat to the muscular fascia which
was then incised over the anterior compartment. This was then
peeled down to the inner muscular septum laterally.  At this
point, we confirmed the presence of one perforator and only
one other perforator was present and this was proximal just
distal to the fibular head. The interseptum was then detached
from the fibula laterally. The muscle cuff was then gently
removed from the periosteum.  Osteotomies were made
proximally and distally and then a distal to proximal
elevation of the fibula with incision of the interosseous
membrane both posteriorly and anteriorly was done. The
peroneal vessels were clipped distally and a much larger
segment of bone was harvested so that we could get as long a
vascular pedicle as possible. We anticipated some potential
problems with isolation of vessels in hand and in the forearm
and this was indeed what we found. The peroneal pedicles were
followed up to the common branch with the posterior tibia
and, at this point, it was ready for transfer.  The
tourniquet was released after approximately 90 minutes.

Simultaneously on the left hand, first the distraction
apparatus was removed.  All 6 pins were removed.  The
extremity was elevated, prepped with Betadine scrub and
Betadine paint and draped in the usual fashion. First the pin
tracks over the fifth metacarpal were curetted. They were
then completely excised. Skin flaps were then elevated in the
anterior and posterior aspects and closed primarily as a
plastic closure. The incision on the forearm coursed the
entire length of the forearm which had been distracted of a
substantial amount. Again, the sites of the pin tracts were
completely excised. The skin in this patient was much more
indurated and soft tissues were not as supple and pliable as
most and certainly not as supple and pliable as they were on
her leg. There was no gross edema but the tissue was just
somewhat indurated and it was much harder mobilizing the skin
flaps on the left hand and the leg area. Old scar, of course,
was excised.  Dissection progressed between the superficial
and deeper layer of abundant subcutaneous fat to mobilize the
skin. The intercalated gap of the fibula was very well
isolated and very well exposed. The bone regenerate had
developed approximately 1 inch on either side of the
osteotomy toward the central portion of the intercalated gap.
The profundus muscle bellies to the ulnar 3 fingers were
palmar. These were isolated from what was present in the
fibula and they certainly had been stretched considerably
during this long distraction. Subperiosteal elevation was
then done.  We then picked a long straight DCP reconstruction
plate from the Synthes set and, with the tourniquet released,
this was fixed with three 4.0 mm cortical screws both
proximal and distal.  Care was taken to off set the plate so
that it was not lying directly on the incision and was
slightly more posterior to it.. With the plate intact, we
then elevated the arm,  re-exsanguinated the arm and turned
up the tourniquet. The ulnar artery had been isolated with
the ulnar nerve in the forearm and this was judged to be
satisfactory. We ideally wanted to convert a micro surgical
problem into a macro surgical one by getting much larger
vessels in the antecubital fossa.  The fossa was exposed with
a transverse incision in the elbow flexion crease. Very
meticulous dissection was done here. Several veins in the
antecubital region were prepared and interestingly, there was
no brachial artery in the normal position. We did not go deep
into the muscle layers and decided to use the arteries. The
artery on the forearm was an end-to-side anastomosis.  We
then had a vein pedicle extending up into the antecubital
region.  Enough of the veins in the antecubital region were
followed into the forearm through this incision as far as
possible so that we would have enough length on both sides,
which we did. However, there was no extra and I'm glad we did
this. With the tourniquet released, the peroneal artery was
anastomosed end-to-side into the ulnar artery at the mid
forearm level. During th dissection, the muscle was in slight
spasm with application of papaverine.  It dilated remarkedly
well and was a good medium sized vessel. End-to-side
anastomosis with simple everting interrupted 9-0 nylon
sutures was uncomplicated and with clamp release, there was
immediate excellent flow into the fibular graft. At this
point,  the forearm posterior incision was closed in layers
using two 3-0 and 4-0 buried Vicryl sutures. Because of the
tightness of the soft tissue, it was not possible to close
the middle third of this wound,  which later in the procedure
was covered with a VAC dressing. The venous pedicle was then
passed over the ulnar nerve which was well mobilized.  Under
the profundus muscles to the ulnar 3 fingers and then through
a subcutaneous tunnel to the antecubital fossa. They were
secured here. The venous leash was then brought up to the
recipient veins. The 2 venous anastomoses were done. One was
large-caliber in the  3-4 mm range with asymmetry which was
gradually dealt with by very careful placement of sutures.
The second vein was 3 mm and was directed end-to-end
anastomosis with 9-0 nylon sutures. No couplers were used.
With the clamp released, there was excellent capillary refill
to all portions of the flap itself. Of the vascularized bone,
no skin portions were included. The sponge count was correct.
Needle count was correct.  The lap count was correct.  The
background count was correct. At this point, we just checked
the antecubital region to make sure that the large clamp had
been removed. The antecubital wound was then closed in layers
using 3-0 and 4-0 buried Vicryl sutures. Penrose drain exited
the medial aspect of the wound. Light compression dressing
was applied. The PIP joints of the ulnar 3 fingers was then
pinned in more extension than normal as they had flexed
during the distraction process. These were held with oblique
.035 C wires in each digit. They were not completely extended
but they are at -35 degrees. When all of the wounds had been
closed, she was then immobilized with a posterior plaster
splint.  A VAC dressing was placed on the forearm.  A
decision has been made to leave the middle third of the wound
open and perform either a delayed primary closure or a
secondary skin graft. She tolerated all of these procedures
quite well.

ESTIMATED BLOOD LOSS:  Negligible.

She was wakened and returned to the intensive care unit in
satisfactory condition. Here she will be monitored and will
be given IV antibiotics and pain medication.

                        [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**]

OPERATIVE REPORT

Name:  [**Known lastname 51955**], [**Known firstname 51956**]        Unit No:  [**Numeric Identifier 51957**]
Service:                          Date:  [**2180-2-11**]
Date of Birth:  [**2158-7-17**]        Sex:  F
Surgeon:  [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**]
ASSISTANT:  Dr. [**First Name (STitle) **] and Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **].

PREOPERATIVE DIAGNOSIS:  Status post vascularized fibular
transfer to left forearm.

POSTOPERATIVE DIAGNOSIS:  Status post vascularized fibular
transfer to left forearm.

OPERATION PERFORMED:
1.  Debridement of wound bed left forearm.
2.  Split-thickness skin graft left forearm.
3.  Application short-leg cast.
4.  Application long-arm posterior plaster splint.

ANESTHESIA:  General endotracheal.

HISTORICAL NOTE:  Less than a week ago vascularized fibular
transfer was done on this young lady who had undergone
approximately 120 mm of distraction lengthening of the
forearm. Because of  skin tightness the wound was not closed
completely. She has been on a VAC, was brought back to the
operating room today for a split-thickness skin graft.

The patient on the operating table supine position with head
of bed up 10 degrees. General endotracheal anesthetic was
induced, LMA tube was used. The dressing was then removed
from the left forearm. There were several blisters in the
areas of old scars. The extremity was then elevated, prepped
with Betadine, scrubbed with Betadine, painted and draped in
the usual fashion. Tangential excision of the wound bed with
some marginal muscle fibers was then performed so we got good
bleeding muscle throughout. This did not require a lot of
debridement. Using the [**Doctor Last Name 17399**] dermatome a split-thickness
skin graft measuring approximately 16,000 __________  was
taken from the anterolateral ipsilateral left thigh. This was
meshed with interstice of 1 to 1.5 and then stapled directly
over the muscle bed. VAC sponge was then custom cut and
placed directly over this and wrapped with Tegaderm in the
usual fashion. The whole VAC apparatus was then hooked up
with good sealed suction. The drain was removed from the
right leg which was the donor leg for the fibula. A well-
padded short-leg walking cast was then placed. Simultaneously
a well padded posterior splint was placed on her arm. She was
then awakened and returned to the recovery room in
satisfactory condition.

                        [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], [**MD Number(1) 24266**]

Brief Hospital Course:
Patient was admitted and underwent surgery on [**2180-2-3**] (please
refer to operative note for details).  She was extubated and
transferred to the ICU for close monitoring and administration
of IV antibiotics and pain medication.  Patient experienced
moderate post-operative pain but declined potential regional
blocks by anesthesia.  Her pain was managed medically with good
control.  She went to the TSICU for close monitoring.

On [**Date Range **] 1, the patient did well and had no major problems.  She
was mildly tachycardic from 106-132, but she was hemodynamically
stable.  Both JP drains remained on suction and she went to the
floor later that day.  The VAC dressing had some problems
holding suctions despite numerous attempts in putting tegaterm
over the foam.  We changed the VAC pump which did not help the
siutation.  We eneded up putting an ioban over the entire
dressing which sealed things nicely. On [**Date Range **] 2, she still had
pain.  Her LUE and RLE were NV intact and labs were drawn as
well.  On [**Date Range **] 3, she got out of bed and sat in the chair without
any difficulty keeping her right leg elevated.  On [**Date Range **] 4, she
got up to the chair again without any problems.  [**Name (NI) 51960**] therapy
stated which she had some difficulty with.  On [**Name (NI) **] 5, the VAC
was changed and the operative site lookeed good.  On [**Name (NI) **] 6, the
foley, heparine, iv abx, and CVL were all d/c.  Additionally,
she bore weight on both LE.  Percocet worked well for pain
control.  On [**Name (NI) **] 7, she was preoped for a split thickness skin
graft to the left forearm.  On [**Name (NI) **] [**9-13**], she tolerated the STSG
well and the donor site was covered with xerofrom.  On [**Month/Day (4) **] [**10-15**],
there were no issues.  On [**Month/Day (2) **] [**11-15**], she continued to do well
without any problems.  On [**Name2 (NI) **] [**12-17**], the patiented expressed her
desire to go home with a vac dressing.  Due to the holdiay, a
vac could not be arranged at the time, but her insurance would
not pay for a vac.  Patient doing much better and due for VAC
change on Friday at the bedside.  On Friday, the VAC was taken
down and the skin staples holding the graft in place were
removed.  There was a small hematoma underneath the graft on the
distal aspect, but no other problems were observed.  She was
dischaged and will follow up in clinic next week.

Medications on Admission:
Valerian occasionally for stress
Percocet, Tylox

Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital **] Homecare

Discharge Diagnosis:
1. Longitudinal deficiency radius, left radial club hand.
2. Camptodactyly, PIP flexion contractures, left long, ring and
fifth fingers.
3.  Congenital absence of left thumb.
4.  Status post first angle distraction lengthening process
5.  Status post removal of distraction apparatus
6.  Scar revision, pin hole tracts ulnar aspect left hand.
7.  Pre vascularized fibular transfer from right leg and left
forearm, w/ plastic closure left leg (35.0 cm), application of
short posterior splint right leg, application of VAC dressing
left forearm, C wire fixation of left long, ring and small
digits and pplication of posterior splint, left arm, elbow and
forearm.
8.  Status post skin graft to left forearm


Discharge Condition:
Stable


Discharge Instructions:
Please take all of your medications as prescribed.
Keep your LUE elevated at all times and avoid strenuous
activities.
You can bear weight on both legs as tolerated.
Please call/return to [**Hospital1 18**] if you experience persistent fever
(Temp>101F), pain/bleeding/drainage/increasing redness/swelling
from the surgical sites.

Followup Instructions:
Please follow-up in Hand Clinic in [**Hospital Ward Name 23**] Building [**Location (un) 470**] on
Tuesday, please call ([**Telephone/Fax (1) 4652**] for an appointment


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]

Completed by:[**2180-2-18**]


RN progress note
neuro: intact, AAO x 3; anxious, cooperative, pain w/ CDB & IS use. Percocet 2 tabs LD 0400.  Slept poorly w/o specific problem.

CV: 1st degree AVB, rare PAC. BP stable.

Pulm: bibasilar crackles, CTAb otherwise. Wheezy cough, prod scant white phlegm. O2 4L/NP. Pt states that he feels "a little breathless" this am, improved with OOB to chair. ?R/T Hct 24.2

GI: poor appetite for late supper. No N/V, no BM. Abd soft, nl BS.

GU: voids frequently, fair output from lasix.

MS/derm: wounds healing, no drainage. Sternum stable.

P: ?transfuse, cont pulm toilet & activity increase.


[**2152-7-3**] 9:50 AM
 HIP UNILAT MIN 2 VIEWS RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # [**Telephone/Fax (1) 39033**]
 Reason: REVISION RT HIP HARDWARE
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Right hip hardware revision.

 Fluoroscopic assistance provided to the surgeon in the OR without the
 radiologist present.  Fluoro time recorded as 1.48 minutes on the electronic
 requisition.  Nine spot views were obtained.  These demonstrate portions of an
 right femoral intramedullary rod and extensive hardware in the proximal right
 tibia, which is incompletely visualized.  A proximal fibular fracture is also
 demonstrated.  A proximal femur fracture is also seen.  Assessment of fine
 bony detail is limited due to RF technique.


NICU NSG NOTE


#1. resp. O/ Remains orally intubated with 2.5 ETT. Current
settings 16/5 x20. FIO2 21%. LS coarse--clear after sx'ing.
Sx'd q4h for sm to mod cloudy secretions. RR 20-30's.
IC/SubC retractions. No bradys or desats thus far this
shift. A/ Stable on current vent settings. P/ Cont to
monitor resp status closely. Monitor for increased
effort/support.

#2. FEN. O/ TF 160cc/k/d. NPO. PND8 and IL via central PICC
in RA. Reaminder of fluifds Sterile H2O with Na Acetate and
hep at 0.8cc/h. Abd soft and flat. BS not audible. UO
3.1cc/k/h for this shift. No stool. DS 74. A/ Alt in FEN r/t
prematurity. P/ Cont to monitor I&O's. DS prn.

#4. G&D. O/ Active with cares. Quiet in between. Eyes remain
fused. Nested on sheepskin. High boundaries. Cares
clustered. Temps stable on radiant warmer. A/ AGA. P/ Cont
tp support developmental needs of infant.

#5. Parenting. O/ Mom called x1. Updated over phone. [**Name (NI) 204**]
brother brought in BM and it was put in the freezer. A/ Mom
is updated. P/ Cont to provide info and support to family.

#6. CV. O/ Re-ECHO today showed PDA present. Murmur not
audible. HR 150-170's. Ruddy earlier this shift--pale now.
BP means 41-49 with pulse pressures 20-25. Pulses full.
Precordium quiet. 2nd course of indocin started this shift.
(Of note, PIV did not flush. After discussion with [**Name (NI) 63**]
Indocin is mixed in D5W and PN/IL were paused for 30mins
during indocin administration. DS prior to PN being stopped
was 74.) A/ Tx'ing for PDA. P/ Cont to monitor closely.

#7. Hyperbili.  Remains on double phototherapy with eye
shields in place. Recheck bili on Sunday per ordered.


[**2191-9-21**] 5:37 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 71459**]
 Reason: r/o free air after paracentesis
 Admitting Diagnosis: GASTROINTESTINAL BLEED,SPONTANEOUS BACTERIAL PERITONITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


49 year old man s/p paracentesis


REASON FOR THIS EXAMINATION:


r/o free air after paracentesis
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Paracentesis, to evaluate for free air.


FINDINGS:


In comparison with the study of [**9-20**], there is continued low lung
 volumes.  Increasing opacification at both bases consistent with layering
 effusion and bilateral atelectatic changes.

 The study is not upright and the possibility of free air cannot be assessed.
 If this is a serious clinical concern, CT would be necessary.


[**2165-10-3**] 1:36 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 34249**]
 Reason: assess for ET placement
 Admitting Diagnosis: RESPIRATORY FAILURE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


51 year old man with misaligned ET tube


REASON FOR THIS EXAMINATION:


assess for ET placement
 ______________________________________________________________________________


FINAL REPORT


CHEST RADIOGRAPH


INDICATION:


Assessment for endotracheal tube placement.


COMPARISON:


[**2165-10-2**].


FINDINGS:


As compared to the previous radiograph, the endotracheal tube is
 unchanged, the tip of the tube projects 6 cm above the carina.  Unchanged
 course of the nasogastric tube, unchanged position of the preplaced left
 central venous access line.  The extent of combined effusion and atelectasis
 in the left hemithorax has further increased, as a consequence the ventilated
 apical lung portions in the left hemithorax have decreased in extent.  No
 changes are seen in the right lung.


[**2183-4-23**] 7:07 PM
 CT C-SPINE W/O CONTRAST                                         Clip # [**Clip Number (Radiology) 106121**]
 Reason: ? head ct fracture, bleed? cpsine fractures, dislocation
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


History:


88M with unwitnessed fall


REASON FOR THIS EXAMINATION:


? head ct fracture, bleed? cpsine fractures, dislocation
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: LLTc WED [**2183-4-23**] 8:25 PM
  No acute fracture or traumatic malalignment of the cervical spine. Moderate
  multilevel degenerative changes.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Fall.

 No comparison studies available.


TECHNIQUE:


MDCT-acquired 2.5-mm axial images of the cervical spine were
 obtained without the use of IV contrast.  Coronal and sagittal reformations
 were performed at 2-mm slice thickness.


FINDINGS:


There is mild reversal of the normal cervical lordosis.  No acute
 fracture or traumatic malalignment of the cervical spine is seen.  There is no
 prevertebral soft tissue abnormality.  Moderate multilevel degenerative
 changes are present, worst at C7/T1, where there is loss of the intervertebral
 disc space with fusion of the left pedicles (602B:51).  The thyroid appears
 normal.  Included views of the lung apices are clear.


IMPRESSION:


1.  No acute fracture or traumatic malalignment of the cervical spine.
 2.  Moderate multilevel degenerative change.


[**2127-5-15**] 6:01 PM
 MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST                    Clip # [**Clip Number (Radiology) 52140**]
 MRA CAROTID/VERTEBRAL W&W/O CONTRAST; MR CONTRAST GADOLIN
 Reason: Eval for brainstem pathology, stroke, arterial issues
 Admitting Diagnosis: LEFT SIDED WEAKNESS;BRADYCARDIA
  Contrast: MAGNEVIST Amt: 20
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


59 year old man with progressive central vertigo, diploplia, left ataxic
  hemiparesis


REASON FOR THIS EXAMINATION:


Eval for brainstem pathology, stroke, arterial issues
 ______________________________________________________________________________


FINAL REPORT


INDICATIONS:  59-year-old man with progressive vertigo, diplopia and left
 ataxic hemiparesis.

 COMPARISONS:  None.


TECHNIQUE:


Multiplanar T1, T2, diffusion and susceptibility weighted images
 of the brain were obtained.  Volumetric FAME images of the brain were also
 obtained prior to and following administration of gadolinium contrast.

 Two- and three-dimensional time-of-flight images of the circle of [**Location (un) **] and
 major vessels of the neck were also obtained.


FINDINGS:


There is no evidence of intra- or extraaxial hemorrhage.  The
 ventricles, cisterns, and sulci are unremarkable.  There is no mass effect,
 hydrocephalus, or shift of the normally midline structures.  The sulci are not
 effaced.  There is abnormally restricted diffusion and T2 hyperintensity, with
 slight swelling of the tissue exhibiting abnormal signal in the left
 posterolateral medulla.  There is no susceptibility artifact at this site.
 Elsewhere in the brain, there are no definite signal abnormalities or areas of
 restricted diffusion or susceptibility artifact.  The major flow voids appear
 patent.

 The osseous structures and soft tissues are unremarkable.

 NECK AND CIRCLE OF [**Location (un) 124**] MRA:  The carotid and proximal vertebral arteries
 appear open bilaterally.  The major arteries of the circle of [**Location (un) **] appear
 patent.  However, adjacent to the area of infarction in the medulla at the
 same level, there is a filling defect in the left vertebral artery, although
 there is persistent distal flow on the time-of-flight images.  Slightly more
 proximally, there is also an area of equivocal stenosis.  The post-contrast
 images of the neck also demonstrate a focal area of expansion of the vertebral
 artery with a filling defect, although distally the left vertebral remains
 opacified.  This filling defect may represent an embolus.  There are no areas
 of aneurysmal dilatation or evidence of arteriovenous malformation.


IMPRESSION:


Acute infarct in the medulla.  Patent left vertebral artery,
 although a probable filling defect is seen within the artery at the same
 level. The findings were discussed with Neurology at the time of
 interpretation.
                                                             (Over)

 [**2127-5-15**] 6:01 PM
 MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST                    Clip # [**Clip Number (Radiology) 52140**]
 MRA CAROTID/VERTEBRAL W&W/O CONTRAST; MR CONTRAST GADOLIN
 Reason: Eval for brainstem pathology, stroke, arterial issues
 Admitting Diagnosis: LEFT SIDED WEAKNESS;BRADYCARDIA
  Contrast: MAGNEVIST Amt: 20
 ______________________________________________________________________________


FINAL REPORT


(Cont)


Baseline artifact.  Sinus tachycardia.  RSR' pattern in lead V1.  There is
somewhat early R wave progression.  Minor ST-T wave abnormalities.  Since the
previous tracing of [**2102-8-24**] the rate is faster.  ST-T wave abnormalities are
more prominent.


PATIENT/TEST INFORMATION:


Indication:


Left ventricular function. Tachycardia.
Height: (in) 67
Weight (lb): 170
BSA (m2): 1.89 m2
HR (bpm): 97
Status: Inpatient
Date/Time: [**2142-10-8**] at 12:09
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: Normal LA and RA cavity sizes.

LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global
systolic function (LVEF >55%).

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal
calcifications in aortic root.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral
annular calcification. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA
systolic pressure.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor subcostal views.

Conclusions:
The left atrium and right atrium are normal in cavity size. Left ventricular
wall thickness, cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild [1+] mitral
regurgitation is seen (within normal limits). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.


IMPRESSION:


Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild aortic regurgitation. Mild
mitral regurgitation.

CLINICAL IMPLICATIONS:
Based on [**2141**] AHA endocarditis prophylaxis recommendations, the echo findings
indicate prophylaxis is NOT recommended. Clinical decisions regarding the need
for prophylaxis should be based on clinical and echocardiographic data.


Admission Date:  [**2132-6-3**]       Discharge Date:  [**2132-6-10**]

Date of Birth:   [**2094-7-19**]       Sex:  F

Service:  CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS:  This is a Russian 37 year-old
female woman with a known history of rheumatic heart disease
and mitral valve prolapse who has been experiencing
progressive shortness of breath on exertion with occasional
chest pain for which she underwent echocardiography and
stress test in [**2131-7-22**].  This revealed moderate to
severe mitral regurgitation.  The patient at that time was
referred for mitral valve surgery, but she declined and has
since reconsidered and was admitted to the hospital for
mitral valve surgery.

PAST MEDICAL


HISTORY:


Rheumatic heart disease, mitral valve
prolapse, scoliosis with severe thoracic and spinal deformity
and chronic back pain as a result of that.  Varicose veins,
chronic headaches, liver cysts noted on echocardiography,
depression, psoriasis and chronic bronchitis.  She is status
post tonsillectomy at age 14.  She is also status post
removal of cyst on her tailbone in [**2116**].

PREADMISSION MEDICATIONS:
1.  Altace 2.5 mg po q.d.
2.  Over the counter medications for headache.

ALLERGIES:  No known drug allergies.

SOCIAL


HISTORY:


The patient is not employed.

PHYSICAL EXAMINATION ON ADMISSION:  Unremarkable.

HOSPITAL COURSE:  The patient was admitted the day of surgery
and taken directly to the Operating Room where she underwent
a mitral valve repair with a #28 mm Carbomedics anuloplasty
ring.  Postoperatively, she was transferred from the
Operating Room to the Cardiac Surgery recovery unit in stable
condition on Neo-synephrine and intravenous Propofol drips.
Postoperatively, the patient required intravenous insulin for
a short period.  She also remained on neo-synephrine due to
some hypotension.  She was weaned from mechanical ventilation
and extubated on the day of surgery.  Her chest tubes
remained in and were discontinued late in the day on
postoperative day one.  On postoperative day two the patient
remained marginally hypotensive requiring neo-synephrine drip
and this prolonged her stay in the Intensive Care Unit.  She
was begun on diuretics and had remained in normal sinus
rhythm with a rate anywhere from the 90s to one teens at that
time.  On postoperative day two she was ultimately weaned off
neo-synephrine and then transferred from the Cardiac Surgery
Recovery Unit to the Telemetry floor.  On postoperative day
three the patient had a blood pressure of 103/68, sinus
rhythm with a heart rate of 108 and room air oxygen
saturation of 97%.  She did have bibasilar crackles and she
complained of intermittent shortness of breath and weakness
at that time.  She was begun on physical therapy and started
to progress with cardiac rehabilitation.

On postoperative day four the patient continued to progress
with cardiac rehabilitation, increased ambulation, remained
tachycardic in the one teens.  Her rhythm was sinus at that
time.  Her blood pressure remained 140s/70s at that time and
her oral Lopressor dose had been increased.  The patient
remained for the next two days somewhat tachycardic again
about 100 to 120 range.  She had a chest x-ray on [**6-8**]
postoperative day five, which showed a left lower lobe
infiltrate possible pneumonia, possible atelectasis and she
was also a bit short of breath at that time.  For this reason
with the tachycardia she stayed in the hospital for two more
days.  Today [**2132-6-10**] the patient remains tachycardic,
although about 100 to 105 for a rate and sinus tachycardia.
Her blood pressure is 115/72.  Her respiratory rate is 20 and
her room air oxygen saturation is 94%.  She had a chest x-ray
yesterday [**6-9**], which showed a significant increase in
aeration of both of her lung fields as well as a decrease in
the opacity in her left lower lobe.  The patient had a small
amount of erythema on her sternal incision with no drainage
and her sternum is intact and stable.  For this she was
started on a five day course of po Keflex.

CONDITION ON DISCHARGE:  Good.  The patient remains afebrile
with previously stated vital signs.  Neurologically she was
alert and oriented.  Her breath sounds she has few crackles
in her left base, otherwise her lungs are clear to
auscultation bilaterally.  She is in a regular rate and
rhythm, which is sinus.  There is slight erythema at the mid
portion of her sternal wound with no drainage.  Her abdomen
is soft, nontender, nondistended.  She has no peripheral
edema and she is at this time below her preoperative weight.
Therefore diuretics have been discontinued today.

MEDICATIONS ON DISCHARGE:
1.  Percocet 5/325 one to two tablets po q 6 hours prn pain.
2.  Keflex 500 mg one po q 6 hours for five more days.
3.  Lopresor 75 mg po t.i.d.
4.  Aspirin 325 mg po q.d.
5.  Colace 100 mg po b.i.d.

FOLLOW UP:  The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]
in approximately four weeks for postoperative check.  She is
to follow up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3357**] in one to two weeks for adjustment of Lopressor
dosing depending on her blood pressure and heart rate at that
time.

DISCHARGE DIAGNOSIS:
Mitral valve prolapse status post mitral valve repair.






                            [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D.  [**MD Number(1) 1540**]

Dictated By:[**Name8 (MD) 964**]
MEDQUIST36

D:  [**2132-6-10**]  07:22
T:  [**2132-6-10**]  13:33
JOB#:  [**Job Number 44348**]


[**2174-9-30**] 8:22 AM
 BILAT LOWER EXT VEINS                                           Clip # [**Clip Number (Radiology) 51610**]
 Reason: HX OF PE, SOB, PLEASE EVAL FOR DVT
 Admitting Diagnosis: CELLULITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


66 year old woman with PMH of morbid obesity, h/o PE, COPD, asthma presented
  from OSH with acute onset of SOB and fevers.  Likely cellulitis of left pannus.
  Please evaluate for DVT.


REASON FOR THIS EXAMINATION:


Please evaluate for DVT
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): [**Last Name (un) 13**] FRI [**2174-9-30**] 10:55 AM
  No deep vein thrombosis identified in either leg.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


66-year-old female with morbid obesity and shortness of breath,
 evaluate for DVT.


COMPARISON:


No previous exam for comparison.


FINDINGS:


Note is made that this is a limited study due to the patient's body
 habitus.  Grayscale, color and Doppler son[**Name (NI) 14**] of bilateral common femoral,
 superficial femoral and popliteal veins were performed.  There is normal flow,
 compression and augmentation seen in all of the vessels.  The tibial veins
 could not be imaged due to the patient's body habitus.


IMPRESSION:


No evidence of deep vein thrombosis in either leg.


NPN 0700-[**2099**]


1. RES: Infant remains in NC 200cc flow, FiO2 60-80%. NC
flow increased during feedings to 400cc. RR 40-70's. Mild SC
retractions. LS clear and equal with mild upper respiratory
congestion. No episodes of apnea or bradycardia. Plan:
Continue to monitor respiratory status.

3. FEN: TF 140cc/kg/d of Portagen 28 gavaged over one hour.
Tolerates feeds well, no spits, no aspirates. Abdomen soft
and round, no loops, +BS. Voiding and stooled x1, guaic
negative. AG 30.5cm. Continues on Trivisol and Vit E per
order. Plan: Continue to monitor FEN.

4. G&D: Infant is cobedding in an OAC with brother. Temps
are stable (slightly high 99.7-100.0), team aware. [**Year (4 digits) 25**] and
active with cares. Fontanels are soft and flat. Infant
received a 7 and 5 on the neonatal narcotic score sheet thus
far today. Receiving 0.3mg morphine q8hr, plan to wean dose
tomorrow per team. Plan: Continue to monitor stress and G&D.


5. PAR: Mom in today and held twins. Very loving and
invested. Asking appropriate questions, updated at the
bedside by this RN. Plan: Continue to educate and support
[**Year (4 digits) **].


Focused Nursing Note
NEURO: Alert, Ox 1 only and with signs delirium AEB confusion, attention span <5 secs, hallucinations, unable to sleep at all, agitated and attempt OOB despite continuous reorientation and incr visibility.  No narcotics since yesterday.  Tylenol x 2 for back discomfort and attempt to calm patient. Moves all extremities equally, follows most commands, no focal neuro deficits. PERRL, 3mm.

RESP: Oxygentating well, titrated O2 to 2-3L NC. Tachypneic at times, self-limiting; lungs with scattered rales, exp wheeze at times which clears with albuterol nebulizer. Frequent pulmonary toileting, pt expectorates small amt yellow sputum, though cough weak.  No sx obstruction noted.

HEMODYNAMICS: Junctional rhythm, rate 60s, no ectopy. SBP range 112-155, SBP > 150 required Hydralazine x 1. At time of hypertension pt also SOB and CVP raised to 18-20- Hydralazine therapeutic.
No edema, no u.o., pending HD today. s/p 1U PRBCs, HCT appropriately raised. Wt up 1 KG. DP/PT pulses by doppler.

ID: Afebrile, Vanco/Gent troughs pending. Rifampin q8hr as ordered.

METABOLIC/NUTRITION: Glucoses stable; TF initiated at 20ml/hr via dobhoff, placement confirmed by audible insufflation. AM labs pending.
Elevated bilirubin, no jaundice, [**MD Number(3) 1132**].

SKIN INTEGRITY: Sternal drsgs C/D/I; Left foot drsg [**Name5 (PTitle) 386**]. Right shin with open abrasion due to pt frequently rubbing shin with contralateral multipodus boot-  boot removed to prevent further trauma and wound care to shin.

PSYCHOSOCIAL: Visited by nephews in evening, pt recognized and answered all questions appropriately, but did not engage unless asked a question and kept eyes closed during visit.

PLAN OF CARE: Risk for respiratory failiure and fluid volume overload: cont pulm toileting, titrate O2 to minimum requirements, plan HD today. Infection: f/u Abx troughs, cont to monitor for sx infection
Nutrition: TF at 20ml/hr, monitor tolerance, nutrition consult in chart. Delirium: Restraints for safety/protection of medical devices, frequent checks, bed alarm/low/locked. Minimal stimulation. Medical treatment plan per primary team. Pt needs sleep aid. Emotional support and education ongoing to pt and family.


Neonatology
RA. COmfortable No spells. No sx PDA. On caffeine.

wt 1415 down 55. Feeds being tolerated at 30 cc/k out of TF=120 cc/k/dAbdomen benign. BS in good range. Will increase TF to 140 and continue feeding advancement.

Under lites in 9 range. Recheck tomorrow.

Completing 48 h r/o.


HPI:53M apparently found down (?in bed) and intoxicated, brought to OSH
   apparently moving all 4 extremities, combative. Intubated, head CT
   showed large left temporal hemorrhage, pt transported to
   [**Hospital1 1**] Ed for further evaluation/treatment.
   CT:large left temporal 8 x 4 cm subacute hemorrhage with right
   frontal small IPH -contracoup. no mass effect or sift.
   Intracerebral hemorrhage (ICH)
   Assessment:
   Patient admitted to SICU off propofol, moving all extremities to
   nailbed pressure.  Purposefully lifting left arm.  Pupils 2 equal and
   reactive to light and brisk.  Unable to follow commands.  Appeared to
   be having a focal seizure involving mostly left arm and left leg.
   Action:
   2 mg IV ativan given, prop gtt started, q 1 hour neuro checks
   instituted. CIWA scale initiated. Keep SBP 100-140 per Dr. [**Last Name (STitle) 3691**].
   Response:
   Neuro status unchanged, Seizure activity stopped after IV ativan and
   prop initiated. SBP 100
s-130
   Plan:
   No plans to go to OR per Dr. [**Last Name (STitle) 4921**] not an acute bleed. Wean off
   sedation, plan to extubated in am?
   Seizure, without status epilepticus
   Assessment:
   Patient arrived to SICU having what appeared to be a focal seizure
   affected left arm mostly. SICU resident and neuro [**Doctor First Name **] PA present
   during seizure activity.
   Action:
   Neuro [**Doctor First Name **] informed. Given 2 mg IV ativan, prop gtt started, CIWA scale
   initiated
   Response:
   No more focal seizure activity noted.
   Plan:
   Continue with seizure precautions, contact neuro [**Name2 (NI) **] if seizure
   activity occurs.


Chief Complaint:  abdominal pain
   I saw and examined the patient, and was physically present with the ICU
   Resident for key portions of the services provided.  I agree with his /
   her note above, including assessment and plan.
   HPI:
   37 year old male with hx alcoholic pancreatitis s/p distal pancr.
   Presented after 4 wk alcohol binge with N/V/abd pain no hematemsis.
   last drink 24 h before admission. No CP/F/SOB/tremors
   In ED 97.6, 76, 145/84, R 20, sats 96% RA. Received 4 liters IVF;
   levaquin/flagyl, dilaudid and transferred to floor. CT abd without
   contrast confirmed pancreatitis.
      On floor, rec'd 2.5 liters fluid but became hypoxic, tachycardic,
   agitated. Repeat labs showed worsening acidosis and increasing lactate.
   Transferred here with P140, RR 26, sats 96% on 100% FM
   Patient admitted from: [**Hospital1 19**] [**Hospital1 158**]
   Patient unable to provide


history:


Sedated/intubated
   Allergies:
   Shellfish
   Anaphylaxis;
   Topamax (Oral) (Topiramate)
   Diarrhea;
   Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
   Diarrhea;
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Other medications:
   Wellbutrin, Fioricet [**Hospital1 7**] prn, Klonipin, gemfibrozil, Methadone,
   Oxycodone, Seroquel, Zanaflex, Advair, Flovent, albuterol
   Past medical


history:


Family


history:


Social


History:


Hx EtOH pancreatitis [**2194**] c/b ARDS, splenic hematoma s/p splenectomy
   GERD
   HTN
   OSA not on CPAP
   chronic pain
   Hyper triglycridemia
   Hx EtOH withdrawals/DT's
   RUQ abscess s/p draininge
   Asthma
   Depression hx suicide attempts (last age 18)
   Occupation:


Chief Complaint:
   24 Hour Events:
   -slight bleeding from around trach site
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2121-9-29**] 10:22 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  [**2121-9-30**] 07:12 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.4
C (99.3
   Tcurrent: 37.2
C (98.9
   HR: 73 (68 - 84) bpm
   BP: 141/67(85) {106/55(68) - 141/67(85)} mmHg
   RR: 14 (12 - 19) insp/min
   SpO2: 95%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 94.5 kg (admission): 100 kg
   Height: 71 Inch
             Total In:
                                                                  1,342 mL
                                                                    324 mL
   PO:
             TF:
                                                                  1,082 mL
                                                                    292 mL
   IVF:
                                                                    185 mL
                                                                     32 mL
   Blood products:
   Total out:
                                                                  2,075 mL
                                                                    700 mL
   Urine:
                                                                  2,075 mL
                                                                    700 mL
   NG:
   Stool:


[**2118-11-8**] 9:25 AM
 CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST              Clip # [**Clip Number (Radiology) 84980**]
 Reason: Characterize pleural effusions, characterize L supraclavicul
 Admitting Diagnosis: HYPONATREMIA
  Contrast: OMNIPAQUE Amt: 130
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


69 year old woman with Hodgkin's disease s/p 2 cycles of AVD, lymphedema,
  pleural effusions, SOB, and L arm > R arm swelling. Poor nutritional status.
  Concern for thoracic duct obstruction and chylothorax.


REASON FOR THIS EXAMINATION:


Characterize pleural effusions, characterize L supraclavicular LAD (r/o
  thoracic duct obstruction). Evaluate for interval changes in LAD now that
  patient is s/p 2 cycles of AVD chemotherapy.
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: TXPb TUE [**2118-11-8**] 11:38 AM
  Bilateral moderate pleural effusions which are consistent in density with
  simple fluid.  Although chylothorax is possible, it is somewhat less likely
  because we would expect the fluid density to be lower due to the increased fat
  content in lymphatic fluid.  Left supraclavicular mass appears similar in size
  to prior studies and probably causes marked compression of the left subclavian
  vein, accounting for L arm swelling and possible thoracic duct obstruction.
  Marked anasarca.  Very little active lymphadenopathy in the chest abdomen or
  pelvis.  Stricture of the IVC in the intrahepatic segment and just superior to
  the bifurcation may be contributing to lymphedema but other non-obstructive
  causes should be pursued.  Diffuse dilation of the large bowel is consistent
  with ileus.  Hydronephrosis has resolved.

 WET READ VERSION #1
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Characterize pleural effusions and left subclavian mass in a
 patient with Hodgkin's lymphoma status post chemotherapy, presenting with
 lymphedema, pleural effusions, shortness of breath, and left greater than
 right arm swelling.


COMPARISON:


CT of the chest without contrast from [**2118-10-10**].  CT
 abdomen and pelvis without contrast from [**2118-10-7**].  Reference CT
 from an outside facility dated [**2118-3-15**].


TECHNIQUE:


MDCT-acquired axial images of the chest, abdomen and pelvis were
 acquired after administration of 130 cc Omnipaque intravenous contrast
 material.  Enteric contrast not given.  Three-minute delay images of the
 abdomen obtained.  Coronal and sagittal reformatted images prepared and
 reviewed.

 DLP:  1686.80 mGy-cm.


FINDINGS:


CHEST:  A 3.6 x 2.4 cm left supraclavicular mass (2:5) seems to extend
 inferiorly and likely causes severe compression of the left subclavian vein
                                                             (Over)

 [**2118-11-8**] 9:25 AM
 CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST              Clip # [**Clip Number (Radiology) 84980**]
 Reason: Characterize pleural effusions, characterize L supraclavicul
 Admitting Diagnosis: HYPONATREMIA
  Contrast: OMNIPAQUE Amt: 130
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 (2:9).  The subclavian artery is patent.  The size is similar to prior
 studies.  There is no further supraclavicular, axillary, mediastinal or hilar
 lymphadenopathy.  A 9 mm left hilar lymph node is somewhat prominent but does
 not meet CT size criteria for pathological enlargement (2:25).  The ascending
 aorta measures 3.8 cm in diameter, which is stable from prior studies (2:23).
 The heart size is normal and there is no pericardial effusion.  There are
 atherosclerotic plaques in the coronary arteries.  There are no central or
 lobar pulmonary arterial filling defects to suggest presence of pulmonary
 embolism.

 The airways are patent.  There is diffuse ground-glass opacity consistent with
 mild pulmonary edema.  There are bilateral moderate pleural effusions with
 associated compressive atelectasis.  The density of the fluid is consistent
 with simple effusion.  There are no pulmonary nodules identified.  There is no
 air space consolidation concerning for pneumonia.  The thoracic esophagus is
 patulous and mostly filled with fluid (2:16).  There is a hiatal hernia to
 (2:37).

 ABDOMEN:  There are no focal liver lesions identified.  There is no biliary
 ductal dilation.  The gallbladder is normal.  Marked narrowing of the
 intrahepatic IVC is noted (300A:38).  Gallbladder, pancreas, and left adrenal
 gland are normal.  There is an indeterminate-density right adrenal nodule
 which is stable in size, measuring 2.4 x 1.3 cm (2:49).  There is a
 subcapsular hypodensity in the spleen, consistent in appearance with a splenic
 infarction, which is not well seen on any of the prior studies (2:47).

 The bilateral kidneys excrete contrast normally and enhance uniformly.  There
 is no hydronephrosis.

 The abdominal aorta is normal in caliber with patent main branches.  The
 portal, splenic, and mesenteric veins are patent.  Note is once again made of
 marked stricture of the intrahepatic inferior vena cava as well as a second
 point of stricture just superior to the bifurcation (4:40).  Previously noted
 extensive mesenteric lymphadenopathy is no longer present.  There is no
 significant portahepatic, aortocaval, mesenteric, pelvic, or iliac
 lymphadenopathy.  There is a trace amount of ascites layering inferiorly
 within the peritoneal cavity (300A:37).  There is no free air or fluid
 collection.

 The stomach, duodenum, and intra-abdominal loops of small bowel are
 unremarkable.  There is diffuse dilation of the colon which contains gas and
 stool, consistent with ileus.  High-density circumferential appearance of the
 large bowel wall is consistent in appearance with prior barium administration.
 There is no evidence of obstruction.

                                                             (Over)

 [**2118-11-8**] 9:25 AM
 CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST              Clip # [**Clip Number (Radiology) 84980**]
 Reason: Characterize pleural effusions, characterize L supraclavicul
 Admitting Diagnosis: HYPONATREMIA
  Contrast: OMNIPAQUE Amt: 130
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 PELVIS:  The urinary bladder is decompressed with a Foley catheter balloon in
 place.  The uterus and ovaries appear unremarkable.  The rectum and sigmoid
 colon are normal.  There is no pelvic mass or lymphadenopathy.

 MUSCULOSKELETAL:  There are two stable hemangiomas within the T8 and L4
 vertebral bodies (301B:47).  There are severe degenerative changes to the
 discs with vacuum phenomenon and endplate sclerosis at multiple levels, most
 severe at L4-L5 where there is grade I anterolisthesis of the L4 on L5.
 Vertebral body heights are stable and there is no focal lytic or sclerotic
 lesion concerning for malignancy.  There is extensive subcutaneous fat
 stranding consistent with anasarca which is markedly worse than the prior
 study on [**2118-10-7**].


IMPRESSION:


1.  Left supraclavicular mass appears similar in size and likely compresses
 the left subclavian vein, accounting for the left arm swelling.

 2.  Moderate bilateral pleural effusions which are simple fluid in density.
 Although chylothorax is possible due to thoracic duct obstruction from the
 supraclavicular mass, it is less likely because the fluid density would be
 expected to be lower given the high fat content of lymphatic fluid.

 3.  Stricture of the intrahepatic portion of the IVC as well as at a point
 just superior to the bifurcation may be due to sclerosis or post-treatment
 changes.  Although this may account for some of the patient's anasarca,
 non-anatomic causes should also be pursued.

 4.  Stable indeterminate right adrenal nodule may reflect involvement with
 lymphoma.

 5.  New splenic infarction.

 6.  Diffuse dilation of the large bowel consistent with ileus.

 7.  No significant active lymphadenopathy within the chest, abdomen or pelvis
 aside from the supraclavicular mass discussed previously.

 8.  Trace ascites.

 9.  Severe multilevel degenerative disc disease.
                                                             (Over)

 [**2118-11-8**] 9:25 AM
 CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST              Clip # [**Clip Number (Radiology) 84980**]
 Reason: Characterize pleural effusions, characterize L supraclavicul
 Admitting Diagnosis: HYPONATREMIA
  Contrast: OMNIPAQUE Amt: 130
 ______________________________________________________________________________


FINAL REPORT


(Cont)


[**2180-7-25**] 10:38 AM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # [**Telephone/Fax (1) 17504**]
 CTA PELVIS W&W/O C & RECONS
 Reason: thoraco-abdominal aneurysm
  Contrast: OPTIRAY Amt:
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


77 year old woman with thoracic and abdominal aneurysm


REASON FOR THIS EXAMINATION:


thoraco-abdominal aneurysm
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


77-year-old woman with thoracic and abdominal aneurysm.

 Comparison is made to the prior CT of torso done on [**2180-5-16**].


TECHNIQUE:


Axial MDCT images were obtained from thoracic inlet to pubic
 symphysis after administration of 120 cc of Optiray.  No oral contrast was
 used.  Sagittal and coronal reformatted images were obtained.  The images
 included a noncontrast set, arterial set and delayed set of images.

 CT OF THE CHEST WITH IV CONTRAST:  The soft tissue windows demonstrate severe
 calcification of the ascending, descending aorta, and coronary arteries.  No
 pathologically enlarged mediastinal, hilar or axillary lymph nodes are
 identified.  No filling defect is noted within the main pulmonary artery and
 its branches to suggest pulmonary embolism.  Incidental note is made of
 aberrant right subclavian artery which has aneurysmal dilatation in its origin
 and is partially thrombosed.  The origin of the left subclavian artery also
 demonstrates severe narrowing and significant calcification and thrombosis.

 Lung windows demonstrate extensive centrilobular and paraseptal emphysema
 scattered throughout both lungs.

 CT OF THE ABDOMEN WITH IV CONTRAST:  The liver, gallbladder, spleen, small
 bowel and large bowel loops are unremarkable.  The right adrenal gland and
 right kidney appear unremarkable.  The left adrenal gland demonstrates a
 nodular area measuring 11 x 12 mm of low attenuation (10 [**Doctor Last Name 137**]). There are
 multiple hypodense lesions of the left kidney which most of them are too small
 to characterize. The larger hypodense lesions most likely represent simple
 cysts. No pathologically enlarged mesenteric or retroperitoneal node is
 identified. No free air or fluid is noted within the abdomen.  Note is also
 made of thoracolumbar aneurysm which will be completely described in CT
 angiogram part.


 CT OF THE PELVIS WITH IV CONTRAST:  The bladder, distal ureters, rectum are
 unremarkable.  The sigmoid colon contains multiple diverticula with no
 evidence of diverticulitis.  No free air or fluid is noted within the pelvis.
 No pathologically enlarged pelvic or inguinal nodes are identified.

 CT ANGIOGRAM:  Aneurysm of the descending thoracic aorta is noted which starts
 above the diaphragm at the level of T11 and ends in the abdominal aorta at the
 level of L1.  The aneurysmal sac ends above the renal arteries. This aneurysm
                                                             (Over)

 [**2180-7-25**] 10:38 AM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # [**Telephone/Fax (1) 17504**]
 CTA PELVIS W&W/O C & RECONS
 Reason: thoraco-abdominal aneurysm
  Contrast: OPTIRAY Amt:
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 measures 36 x 35 mm in its lumen and 38 x 35 mm in its sac. The celiac artery
 and superior mesenteric artery originate from the sac. There is severe
 narrowing at the origin of the celiac artery for approximately 1.2 cm and at
 the origin of the SMA, which extends for approximately 3.7 cm. The origin of
 the inferior mesenteric artery is also severely narrowed. The root of aorta
 measures 13 x 22 mm.

 BONE WINDOWS:  No concerning lytic or sclerotic lesions are identified.  The
 patient is status post dynamic hip screw placement of the left hip.


IMPRESSION:


1. Thoracolumbar descending aortic arch aneurysm that starts above the
 diaphragm and ends above the origin of the renal arteries and gives origin to
 the celiac and superior mesenteric artery. The origin of the celiac and
 superior mesenteric artery demonstrates severe narrowing.

 2.  Aneurysmal dilatation with mural thrombus at the origin of an aberrant
 right subclavian artery.

 3.  Significant narrowing and calcification of the origin of the left
 subclavian artery.

 4.  Diffuse centrilobular and paraseptal emphysema.

 5.  Left adrenal gland adenoma.


[**2177-1-20**]:  CABG x 3 lima to lad, svg to om, svg to diag, AVR # 23
   bioprosthetic.  EZ intubation, **CHB out of OR, AV paced, third V wire
   placed**
   Coronary artery bypass graft (CABG)
   Assessment:
   Neuro:  Intact, AOx3, MAE, lifts and holds but soar and weak, follows
   commands
   CV:  AV Paced with underlying rhythm of NSR with frequent PAC/atrial
   bigeminy, symptomatic with over-sensing and intrinsic rhythm returning
   pauses between beats or skipped beats result with hypotension,
   otherwise BP >100 MAP >60,
   Resp:  LS clear in upper lobes but crackles on lower lobes, 4 liters NC
   sats 100%, RR 20
   GI:  Soft, non-tender abdomen with absent BS, no difficulty swallowing
   sips and ice chips
   GU:  Patent foley with clear yellow urine draining adequate amounts
   hourly
   Endo:  Received on insulin gtt
   Pain:  Patient mainly describes moderate discomfort while trying to
   take deep breaths
   Action:
   CV:  Monitored lytes, while asleep, pressure decreased SBP 85, MAP 55,
   placed on low dose Neo through the night
   Resp:  Titrated O2 as tolerated, encouraged CDB
   Endo:  BS every hour
   Pain:  Gave 2mg morphine for [**2177-8-26**] pain only
   Response:
   CV:  Repleted K and I.Ca, monitor underlying rhythm, wean Neo gtt for
   the am
   Resp:   Weaned O2 to 2 liters NC, no periods of apnea
   Endo:  Weaned from gtt
   Pain:  Patient appears to be resting comfortably
   Plan:
   Off pacer and insulin gtt by the morning, maintain patient safety


addendum:

patient became hypoglycemic @ 0200 FS 45; wasnt able to give D50W [**1-13**] amp due to no good IV access. Patient had been continuously moving arm, PIV at L hand leaking at insertion site. Tried to insert twice to no aware,,very difficult to access. Team aware ? PICC insertion, call for IV nurse. FS 100mg/dl post 4 oz [**Location (un) 281**] juice, RISS scale modified.


t-sicu nsg note:
neuro- remains sedated on fentanyl gtt no ativan given, grimaces to inc stimulation, perrla 2mm, weak cough, no spont movement.

resp- coarse bs throughout, vent settings unchanged other than inc fio2 to 90%, pao2 85, remains acidotic.

cvs- levo presently @ 0.5mcg/kg/min to maintain map 65-70, tm 99.4core, cvp 18-19, pap's 50's/30's, co 7.49. lytes wnl

gi- abd soft/distended, hypoactive bs, ogt w/ bilious drainage, colostomy w/ sm amt mucoid drainage.

gu- gd uo, no diuretics given overnight.

skin- oozing from various sites, coccyx w/ stg II and yeast. antifungal applied.

social- daughter [**Name (NI) 398**] in to visit this am, discussed cmo for later today, family does not want any cardioversion/defibrillation should pt require it.

a:cont to require full support

p: monitor cvs/nvs per routine,cont present hemodynamic support, family meeting today, support family decisions.


[**Last Name (LF) 2288**],[**First Name3 (LF) 2289**] P.            TSURG SICU-A               [**2112-11-2**]  4:50 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 113190**]
 Reason: Eval interval film
 Admitting Diagnosis: BLEEDING CHEST WOUND
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


53 year old man with open chest


REASON FOR THIS EXAMINATION:


Eval interval film
 ______________________________________________________________________________
                                  PFI REPORT
 1.  Tiny right apical pneumothorax unchanged.
 2.  Right PICC line is again seen projecting over the right atrium 2.5 cm
 beyond the cavoatrial junction.


T/SICU NURSING PROGRESS NOTE

PLEASE SEE CAREVUE FOR EXACT DATA

REVIEW OF SYSTEMS:

NEURO-Pt sedated on Propofol, weaned to 20mcgs/kg/min. Off sedation (x30-40mins) pt with spontaneous eye opening, occ tracking, purposeful with LUE reaching for ETT, MAE's. Does not follow commands. Bilateral LE's with triple flexion to nailbed pressure and +babinskis reflex. Pupils [**2-28**] bilaterally and [**Last Name (un) 2567**] reactive.  Fentanyl given PRN for pain. Neuro checks q2hours.

CV-NSR rate 70-80's first degree HB, occ APC's/PVC's noted. K+ WNL. SBP by NIBP ranging 130-150, arterial line with fling and ranging 140-170's, gaol SBP <160. Pt with stable anemia. PIVx2. Compression boots bilaterally for prophylaxis.

RESP-Pt orally intubated with #8 ETT 23LL, retaped and rotated this shift, Continues on PSV 5/5 40% Suctioned for copious amounts of tan thick secretions. Lung sounds clear bilaterally. Sputum culture sent this shift. Mouth care given per VAP protocol.

GI-NGT with Replete with fiber at goal 80cc/hr, no residuals noted. Present bowel sounds. No BM since admission, bowel protocol continues, suppository given this shift. H2b for prophylaxis.

GU-Indwelling foley catheter with adequate uop.

ENDO-RISS with fixed dose coverage.

ID-Tmax 101.2, sputum culture pending. Tylenol given.

SOCIAL-No family contacts overnight.

PLAN-Repeat head CT today, spoke to neurosurgery re: family request to meet with them (no offical meeting planned at this time), continue to monitor neuro status, ?change neuro check frequency, montior hemodynamics and resp status.


Neonatology Attending Note
DOL# 33, CGA 39 [**12-27**] wk

In RA
GOod sats, clear BS
RR 30-50s

P 140-170s
MBP 52

Wt 2760 (up 45gm)
TF 150 cc/kg BM 24
Still with poor POs

Voiding and stooling
No spits, [**Month/Day (4) **] aspirates
Some oral thrush

A/P:
Premature infant with feeding immaturity
RESP:  Continue to monitor resp status
CV:  Stable
FEN:  Continue to work on PO feeds on current nutritional regimen
SOC:  Plan to update [**Month/Day (4) 32**]


Fellow note; physical exam
[** **] and active. Breathing comfortably on CPAP. Skin pink. AFOF. MMM. Lungs with good aeration and clear breath sounds bilaterally. RRR. Nl S1, S2. No murmur. Normal femoral pulses. Abd full, soft, +BS. Extremities warm and well-perfused. Good tone.


[**2184-10-1**] 5:06 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 20397**]
 Reason: r.o pneumonia
 Admitting Diagnosis: BILE DUCT INJURY
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


78 year old woman with comp colecystectomy.


REASON FOR THIS EXAMINATION:


r.o pneumonia
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Complicated cholecystectomy, exclude pneumonia.


COMPARISON:


Radiographs dated [**2184-9-30**] and [**2184-9-6**].


FINDINGS:


Diffuse opacity projected over both lower lobes most likely
 reflects posteriorly layering bilateral moderately large pleural effusions
 which appear to have worsened since yesterday.  Alveolar edema and mild
 cardiomegaly are unchanged since [**2184-9-30**].  The tracheostomy tube, left
 subclavian central venous catheter, and right upper quadrant pigtail catheter
 are unchanged, in satisfactory position.


IMPRESSION:


1.  Increase in size of bilateral moderately large pleural effusions.

 2.  Stable mild pulmonary edema.


CCU Nursing Progress Note
S-"I can't believe that I had another heart attack".
O-Neuro alert and oriented x3, pleasant and cooperative but anxious and in denial about his heart attack. Has decided to follow a hollistic approach and has not taken asa or toprol.
CV-No c/o chest pain although still having left shoulder discomfort upon admission to the unit, unchanged from the cath lab. SBP 150-170/80-100 with HR 68-88 NSR 1 non sustained run VT ( see strip in chart) PAP 36/16. Started lopressor 25mg po BID at 1730. Integrelin at infusing @ 2mcg/kg/min. Right fem art/venous sheaths removed at 1600. Small hematoma 3cm above insertion site. No further bleeding and pedal pulses intact.
Resp-LS clear O2 2lnp with O2 sats 97-99%.
ID-afebrile
GI-No c/o n/v, pt follows a strict vegetarian/vegan diet. Dietican to see pt in am to assist with menus. +BS
GU-condom catheter urine qs. IVF 1/2 NS at 125cc/hr for 2.5liters.
Skin-intact.
Assess-2 PIV.
Social-lives alone. Called mother in [**Name2 (NI) **].
A/P-RI STEMI Inf/lat s/p LCX stent
Check serial CPK's q8hrs.
d/c integrelin at 0530 [**1-21**].
1/2 NS for 2.5 liters.
Gradual increase in betablocker as tolerates.


[**2163-2-27**] 1:46 PM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 30062**]
 Reason: pneumonia?
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


89 year old man with cough


REASON FOR THIS EXAMINATION:


pneumonia?
 ______________________________________________________________________________


FINAL REPORT


STUDY:  PA and lateral chest radiograph.


INDICATION:


Cough.


COMPARISON:


[**2163-1-14**].


FINDINGS:


There is minimal change from previous radiograph.  Opacity again
 noted at the left lung base is consistent with a pleural plaque.  No focal
 consolidation is detected.  No effusion or pneumothorax is present.  The
 cardiac and mediastinal silhouettes are unchanged.  There is unchanged
 compression deformity of the mid thoracic vertebral body.  The thoracic aorta
 is unfolded and tortuous, unchanged.  There is mild gaseous distention of the
 visualized colon.  No free intra-abdominal air is detected.


IMPRESSION:


No focal consolidation to suggest pneumonia.


Chief Complaint:
   I saw and examined the patient, and was physically present with the ICU
   Resident for key portions of the services provided.  I agree with his /
   her note above, including assessment and plan.
   HPI:
   24 Hour Events:
   - D/C'ed ctx and levo s/p course for PNA
   - EEG with widespread encelopathy, no seizures
   - PICC deferred [**2-20**] elevated INR
   - Persistent delerium
   Allergies:
   Penicillins
   Unknown;
   Sulfa (Sulfonamides)
   Unknown;
   Erythromycin Ethylsuccinate
   Unknown;
   Zithromax (Oral) (Azithromycin)
   Abdominal pain;
   Zofran (Injection) (Ondansetron Hcl/Pf)
   Confusion/Delir
   Last dose of Antibiotics:
   Ceftriaxone - [**2192-7-17**] 08:00 PM
   Levofloxacin - [**2192-7-18**] 09:13 PM
   Infusions:
   Other ICU medications:
   Other medications:
   Changes to medical and family


history:


PMH, SH, FH and ROS are unchanged from Admission except where noted
   above and below
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2192-7-20**] 10:05 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.3
C (99.2
   Tcurrent: 36.2
C (97.2
   HR: 84 (73 - 94) bpm
   BP: 109/39(54) {81/28(40) - 119/85(88)} mmHg
   RR: 22 (16 - 29) insp/min
   SpO2: 96%
   Heart rhythm: AF (Atrial Fibrillation)
   Wgt (current): 110.8 kg (admission): 90 kg
   Height: 64 Inch
   CVP: 8 (4 - 17)mmHg
   Total In:
                                                                  1,716 mL
                                                                    736 mL
   PO:
   TF:
                                                                    799 mL
                                                                    405 mL
   IVF:
                                                                    367 mL
                                                                    101 mL
   Blood products:
   Total out:
                                                                    290 mL
                                                                    135 mL
   Urine:
                                                                    290 mL
                                                                    135 mL
   NG:
   Stool:


[**2155-2-11**] 3:03 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 37478**]
 Reason: evaluate for interval change
 Admitting Diagnosis: LUNG CANCER;SHORTNESS OF BREATH
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


59 yo male h/o metastatic NSCL CA; s/p thoracentesis.


REASON FOR THIS EXAMINATION:


evaluate for interval change
 ______________________________________________________________________________


FINAL REPORT


AP CHEST FROM [**2-11**].


HISTORY:


Metastatic lung carcinoma following thoracentesis.


IMPRESSION:


AP chest compared to [**2-4**] and 12:

 Bilateral lower lobe collapse persists.  Moderate left and small right pleural
 effusions are larger.  Upper lungs clear.  Heart size is normal.  Tip of the
 left subclavian line projects over the mid SVC.  No pneumothorax.


CVICU
   HPI:
   68M  with ESRD POD 2  from AVR (#23St [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2866**]), complicated by
   post-op shock requiring vassopressin and levophed, now on CVVH
   Chief complaint:
   PMHx:
   HTN, AS, asthma, hiatal hernia repair, RA, anemia, right AV fistula, B
   cataract surgery, bladder CA s/p cystoscopy and tumor removal, HF,
   sleep apnea on BIPAP, PAF, DVT, s/p embolectomy Rt fem clot, Type II
   DM, peripheral neuropathy, psoriasis, PPM, ESRD on HD(MWF), COPD,
   depression
   Current medications:
   24 Hour Events:
 DIALYSIS CATHETER - START [**2183-1-21**] 12:23 PM
   - Continued on vent
   - Dialysis catheter placed and CVVH started
   - Continued high pressor requirement
   Post operative day:
   POD#2 - AVR mechanical
   Allergies:
   Quinolones
   Anaphylaxis;
   Levofloxacin
   Unknown;
   Lorazepam
   Unknown;
   Last dose of Antibiotics:
   Vancomycin - [**2183-1-22**] 07:53 AM
   Infusions:
   Vasopressin - 3.6 units/hour
   Calcium Gluconate (CRRT) - 1.2 grams/hour
   Fentanyl - 25 mcg/hour
   Midazolam (Versed) - 2 mg/hour
   Norepinephrine - 0.2 mcg/Kg/min
   Insulin - Regular - 2 units/hour
   KCl (CRRT) - 2 mEq./hour
   Other ICU medications:
   Insulin - Regular - [**2183-1-22**] 12:30 AM
   Fentanyl - [**2183-1-22**] 08:00 AM
   Heparin Sodium (Prophylaxis) - [**2183-1-22**] 08:15 AM
   Pantoprazole (Protonix) - [**2183-1-22**] 08:16 AM
   Other medications:
   Flowsheet Data as of  [**2183-1-22**] 11:18 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**85**] a.m.
   HR: 90 (81 - 104) bpm
   BP: 87/42(56) {81/39(51) - 128/84(74)} mmHg
   RR: 13 (13 - 20) insp/min
   SPO2: 98%
   Heart rhythm: AF (Atrial Fibrillation)
   Wgt (current): 120.4 kg (admission): 109.5 kg
   Height: 73 Inch
   CVP: 15 (14 - 22) mmHg
   PAP: (46 mmHg) / (26 mmHg)
   CO/CI (Fick): (7 L/min) / (3 L/min/m2)
   CO/CI (CCO): (6.1 L/min) / (2.7 L/min/m2)
   SvO2: 65%
   Mixed Venous O2% sat: 69 - 69
   Total In:
                                                                  6,201 mL
                                                                  3,750 mL
   PO:
   Tube feeding:
   IV Fluid:
                                                                  5,559 mL
                                                                  3,750 mL
   Blood products:
                                                                    562 mL
   Total out:
                                                                  3,427 mL
                                                                  3,252 mL
   Urine:
                                                                     13 mL
   NG:
                                                                  1,050 mL
                                                                    300 mL
   Stool:


NPN 1900-0700
Neuro: Sedation continues to be weaned, Fentanyl @ 30 mcg/hr, and Midazolam at 2.5mg/hr IV, continues to not follow commands, no purposeful mvmts, opens eyes spontaneously, R pupil 3mm and [** **], L pupil 3mm Brisk, grimaces when being turned and sx'd. CT head [**12-22**] showed "area of low attenutation in L occipitoparietal lobe c/w infarction of uncertain age."

Resp: Lungs Coarse throughout, sx'd small amts of whitish thick secretions per ETT, scant white secretions sx'd from mouth, cont. CPAP with PS 18/10/40%/400, RR 20-30's and O2 sats 96-100%.

CV: HR 66-98 WAP with frequent PAC's and PVC's, BP's 131-156/30-50's, CVP 8-11, general anasarca, pedal pulses palpable bilat.

ID: Tmax 97.8, cont. Imipenem, Voriconazole IV.

Endo: FBS 140-267 restarted on insulin gtt 2u/hr at 0400, inuslin also in TPN.

GI: BS (+) x 4 quad., abd softly distended, no BM this shift, Criticare infusing at 10cc/hr with residuals 20-40 cc/hr. TPN infusing at 62.5cc/hr.

GU: Foley cath intact draining clear yellow urine in adequate amts.

Plan: Continue to wean vent. support as tolerated, advance TF to goal, monitor UO, support family.


(Continued)
 IS PURPLE/BLACK,NO BREAKDOWN. MULTI PODUS BOOTS IN PLACE. LEFT GREAT TOE IS PURPLE AND SEVERAL OTHER TOES BLUE TINGED. INCISIONS STILL HAVE STERI STRIPS,SLIGHTLY RED ALONG BORDERS. NO DRAINAGE. CT SITE D&I. SEVERAL BLOOD BLISTERS. ANASARCIC.

SOCIAL: DAUGHTER [**First Name4 (NamePattern1) 73**] [**Last Name (NamePattern1) 7861**] IS SPOKESPERSON CELL PHONE [**Telephone/Fax (1) 7862**],HOME [**Telephone/Fax (1) 7863**]. HUSBAND HAS [**Name (NI) 5621**] AND DAUGHTER HAS REQUESTED THAT ONLY AN UPBEAT TONE AND NEWS BE GIVEN TO HER FATHER.

NEURO: ON ATIVAN 2MG/HR AND FENT AT 25MCG/HR. PT OPENS EYES TO NAME AND HAS NODDED HEAD TO QUESTIONS.

A/P: PLAN FOR OR TO PLACE CT'S AND REMOVE PACING WIRE.


Neonatology Attending

Day 14  PMA 35 [**4-23**] wks

Remains in RA.  RR 40-60s.  No bradycardia.  Clear breath sounds.  No murmur.  HR 140-170s.  Pink.  BP mean 56.  Weight 2435 gms (-40).  TF at 140 cc/kg/d- PE 24.  Still taking partial bottles.  Occasional spit, gastric residuals.  Stable temperature in open crib.  Waking for some feeds.

Doing well overall with mature breathing control but continued immature, improving feeding.  Will continue to monitor and encourage feeds.  Family up to date.


[**2160-9-17**] 4:58 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 92765**]
 Reason: pna? pulm edema?
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


60 year old woman with sob and hypotension


REASON FOR THIS EXAMINATION:


pna? pulm edema?
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


60-year-old woman with shortness of breath and hypotension.
 Assess for pneumonia or pulmonary edema.


COMPARISON:


Multiple priors, most recently chest radiographs and CTA of the
 chest of [**2160-9-10**].

 SINGLE FRONTAL VIEW OF THE CHEST:  Superior vena cava and brachiocephalic vein
 stents are unchanged in position.  Moderately severe cardiomegaly is similar
 to the prior study.  Previously seen left basilar opacities have improved in
 addition to pulmonary edema from the [**2160-9-10**] study.  There is mild
 blunting of the left costophrenic angle, likely a residual small pleural
 effusion.  There is no pneumothorax.  Mediastinal contours are unchanged.


IMPRESSION:


Compared to the [**2160-9-10**] study, pulmonary edema and small
 left pleural effusion has improved.  No new areas of focal consolidation
 concerning for pneumonia.


Atrial paced rhythm, at 70 beats per minute with intrinsic A-V conduction.
Prior anteroseptal myocardial infarction. There are persistent ST segment
elevations in leads V1-V3 and T wave inversions in leads V4-V6. Compared to
the previous tracing of [**2193-5-4**] no diagnostic interval change.
TRACING #1


[**2164-4-13**] 11:14 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 37893**]
 Reason: sdh status
 Admitting Diagnosis: INTRACRANIAL HEMORRHAGE
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


89 year old female with SDH from fall 2 weeks ago, mental status not
  improving and respiratory decompensation,  now intubated


REASON FOR THIS EXAMINATION:


sdh status
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


CT HEAD WITHOUT CONTRAST, [**2164-4-13**]:


HISTORY:


Subdural hematoma from fall 2 weeks ago.  Mental status change.

 Contiguous axial images were obtained through the brain.  No contrast was
 administered.

 Comparison to a head CT of [**2164-4-4**].


FINDINGS:


There has been enlargement of the right convexity subdural hematoma
 since the study of [**2164-4-4**].  This is associated with an increase in mass
 effect upon the sulci and upon the right lateral ventricle.  There is minimal
 right to left midline shift, but this is slightly more prominent than on the
 prior study.  Again seen are several areas of subarachnoid hemorrhage.  These
 have decreased in density since the previous study.  There is also a small
 amount of subdural hemorrhage along the falx.  This is less prominent than
 on the prior study.  Again identified is extensive atrophy with enlargement of
 the ventricles and sulci. There is extensive periventricular hypodensity of
 the white matter suggesting chronic small vessel ischemia.

 CONCLUSION:  Enlargement of right convexity subdural hematoma since [**2164-4-4**].


Sinus rhythm with atrial premature beats. Since the previous tracing the rate
has slowed and the mechanism has returned to sinus.
TRACING #2


NPN 1900-0700

7 Cardiovascular

RESP: IMV 16/5 X14. FiO2 mostly 21%, does need to be
increased for cares, IV placement and CXR. O2sat 95-99%. RR
40-60's. LS coarse/clear bilaterally, clear after sxn'ing.
Slightly diminished breath sounds on left side at 01 cares,
[** 13**] notified and in to examine. IC/SC rtx noted. On
caffeine. No brady's, but did have a desat to 76%, requiring
increase in FiO2 to 40%, but weaning back to 21% quickly
after. Chest tube to water seal, no drainage or air noted.
At 0430, CXR done.

G&D: Temp stable, nested on sheepskin on servo-warmer. Alert
and active with cares. Sleeps well between. Receiving
fentanyl with each cares for pain/stress management, with
good results.

[** **]: Both [** 32**] in for 2100 cares. Updated at bedside
by this RN and by [**First Name9 (NamePattern2) 13**] [**Doctor Last Name 222**]. Dad took temp, took lots of
pictures on infant while on scale. Stayed in parent room
overnight. Plan to be in later this morning.

FEN: wt=1kg. (up 10g). TF=120cc/kg/d. NPO. IVF PND10 with IL
via PIV. Abdomen soft, hypoactive bowel sounds.
UO=2.6cc/kg/hr X12 hrs. No stool, given rectal stim X2 with
no results. AG 18-19 cm. no loops noted. D-stick 91. Lytes
sent, results pending.

Bili: Single phototherapy with eye shields on. Pale pink,
slightly jaundiced. Bili sent, results pending.

CV: Loud murmur heard at 01, [**Doctor Last Name 13**] notified, in to examine
infant. Warm, well-perfused. Pale pink, slightly jaundiced.
Crit 39.6.

REVISIONS TO PATHWAY:

  7 Cardiovascular; added
    Start date: [**2135-11-27**]


NP NOTE
PE: well developed infant swaddled in open crib,pink, ruddy well perfused in RA.
AFOF sutures approximated, eyes clear, ng in place,MMMP
Chest is symmetric with clear, equal bs, comfortable
CV: RRR, no murmur, pulses+2=
Abd: soft with active bs, NTND, cord dry
GU: testes in scroyum
EXT: MAE
Neuro: active good tone, symmetric primitive relfexes


61 y.o. female with DM, HTN, dCHF, COPD, obesity hypoventilation
   syndrome, who was admitted to [**Hospital3 **]on [**2193-1-24**], after being
   found unresponsive at home by her husband.  Unclear how long down
   (husband returned from work 4:30PM, pt last seen in AM).  She had
   hypercarbic and hypoxemic resp failure (initial sats 60s, ph 7.12, pCO2
   120s) and was intubated.  Her OSH course by system:
   Respiratory:  Initially had total collapse of left lung, and underwent
   bronchoscopy upon admission, ? mucous plug.  BAL growing GPCs (no
   speciation reported or sent).  Treated with Vanco/Levo/Zosyn from [**1-24**],
   but vanco stopped [**1-29**] when MRSA screen negative.  Remains intubated,
   on assist control, 500, 18, (breathing 19-20), FIO2 0.4, peep 5.  ABG:
   7.16/52/98.  Sedation with propofol.
   CV: Was intially hypotensive, placed on levophed.  This was weaned
   within 48 hours admission.  Lactate borderline elevated initially, no
   repeat.  Has had to be placed back on levophed x last 2 days prior to
   tranfer for recurrent hypotension
   Renal:  Initially normal renal fx.  Cr began to rise shortly after
   admission, and still rising (today 6.8).  Persistent hyperkalemia,
   acidemia.  Bicarb falling.  Receiving Kayexalate and insulin gtt
   ID: MRSA screen neg.  Sputum from admission growing GPCs, but no
   speciation reported.  Urine growing proteus.
   Endo: H/o DM, currently on Insulin gtt
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 2**])
   Assessment:
   Remains intubated on AC 40%, LS diminished. Sat 95-96%.pt start on
   fentanyl/versed, pt withdraw to pain, opens eyes to pain
   Action:
   Multiple ABG sent and a few vent changes made, please see metavision.
   start  bicarb gtt and given amp bicarbx2, given nebs tx.
   Response:
   Currently AC 40%/500/RR24/peep 10. d/t dropping on BP fentanyl down to
   125 from 150mcg/hr nad versed down to 3mg/hr from 4mg/hr
   Plan:
   Cont follow ABG, pulmonary toilet as needed
   Renal failure, acute (Acute renal failure, ARF)
   Assessment:
   Bun/CREAT/115/7.5, initially with normal renal function creat at
   baseline 1.3
   Action:
   Start bicar gtt 100cc/hr ,given bicarb ampx2.
   Response:
   u/o remains 5-15cc/hr, MD aware
   Plan:
   Renal consult . line placement  and possible CRRT
   Hypotension (not Shock)
   Assessment:
   Bp 100/50
s with Map56-57, likely d/t sepsis.  afebrile.
   Action:
   Aline placed, start Levophed to keep MAP>65
   Response:
   Unable to wean levophed down Map drops to 58, goal Map>65.currently
   levophed at 0.22mcg/kg/min WBC  up 10 22 from 19.pan cx sent. Cont
   Zocyn.
   Plan:
   Wean Levophed to keep MAP>65 or start second pressors as needed.
   Hyperkalemia (high Potassium, Hyperpotassemia)
   Assessment:
   K 6.8
   Action:
   Given Kayexalate, start on insulin gtt, keep BS 100-150
   Response:
   Morning K 5.2
   Plan:
   Cont follow lytes
   Pt has TLC LS from OSH, needs to be changed.
   Ca 6.8 repletd with 2gr, morning ion Ca 0.94, repleted with 2gr


NPN 7a-7p
Neuro: Sedated on 100mcg/hr of Fentanyl and 60mcg/hr of Propofol. Opens eyes to voice and pain.  Moves all extremities.  ? follows commands such as take a deep breath.
CV: No ectopy BP stable 130-150's.  HR 70-80's.
Resp: Has remained on A/C during the day but PEEP has been weaned down to 5 with sats in 98's.  Initially had sats 92-94 but improved after suctioning.  Last ABG-7.46/33/92.  Has small amount of rust colored sputum.  Plan is to have pt. on pressure support during the day and vented at night, currently seeing how he does on decreased PEEP then trial of PSV.
ID: Pt. developed a ? drug rash on his back which has spread to his face. ? r/t oxacillin which was the most recent antibiotic. Oxacillin d/c'd this am.  Remains on clinda/levo for wound infection and pneumonia.  TMax 100.6.  Was febrile to 102 last night-? drug fever. WBC is decreasing and all recent cultures have been negative.
Skin: Dressing changed today by surgery.  Felt the wound is healing well, no purulent drainage.  Some debridment was done.  No plans for surgery in the immediate future.
GI: Tube feeds at goal of 40cc/hr.  Passing small amounts of liquid stool.
GU: Autodieurising well.  No lasix given this am.  Urine output approx. 80-100cc/hr.
Social: Family in to visit.


NPN 7a-7p


FEN:  TF 140cc/k/d of BM/PE24 = 53cc Q4hrs PO/PG; gavaged
over 1hr45min.  No attempt to bottle as of yet d/t low temps
this morning; infant not acting eager to bottle.  Plan to
offer PO @ next feeding. Abd. benign. Girth 26.5cm.  Max asp
5cc partially digested formula; non-bilious, refed.  Voiding
and stooling; heme neg.  Infant tolerating feeds well; no
spits.  Continue to encourage PO's as tolerated and
supplement via gavage.

SOCIAL:  Mom called x1.  Updated by this RN.  Asking
appropriate questions.  Continue to update and support.

DEV:  Infant cobedding with brother in [**Name (NI) 5**].  Temp this
morning (96.7-97.5axillary).  Double swaddled with warming
lights; infant temp stablized @ 98.0axillary, 99.3ax @ last
care.  Alert and active with cares; sleeping well in
between.  Occ. waking for feeds.  Likes pacifier.  MAE.
Continue to monitor temps and support developmental needs.


[**2176-9-27**] 5:46 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 63608**]
 Reason: please evalute effusions
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


84 year old man s/p sdh evacuation, s/p anterior wall MI in chf with
    bilateral effusions.


REASON FOR THIS EXAMINATION:


please evalute effusions
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Follow up pleural effusions, s/p anterior myocardial infarction.

 PORTABLE CHEST: Comparison is made to [**2176-9-26**]. The tracheostomy tube and left
 PICC are in stable position. There is persistent cardiomegaly and pulmonary
 edema. There are pleural effusions bilaterally, greater on the left, which
 have increased slightly from the prior study.


IMPRESSION:


Persistent CHF with slightly increased pleural effusions, greater
 on the left.


Chief Complaint: hypotension and fever
   24 Hour Events:
   - f/u CT torso --> could not perform [**2-14**] to poor access
   - getting nutrientional cs
   - f/u 3 pm hct: stable
   - heme-onc:
   - Giving 4 L of fluid bolus and UOP still not elevated, about 2 L came
   out from ostomy.
   - UA: Uric Ax few, slight protein, no leuk/nitrite, trace ketones.
   - ULytes: (if high Na, worry about ATN): FeNa = 0.43, appears to be
   prerenal.
   Allergies:
   Latex
   Rash;
   Oxaliplatin
   see ccc note;
   Iodine; Iodine Containing
   Rash;
   Fluconazole
   angioedema;
   Ace Inhibitors
   Rash; contraind
   Last dose of Antibiotics:
   Vancomycin - [**2164-4-18**] 08:00 AM
   Piperacillin - [**2164-4-19**] 12:00 AM
   Piperacillin/Tazobactam (Zosyn) - [**2164-4-20**] 12:00 AM
   Infusions:
   Other ICU medications:
   Pantoprazole (Protonix) - [**2164-4-19**] 08:06 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  [**2164-4-20**] 07:43 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**66**] AM
   Tmax: 37.1
C (98.7
   Tcurrent: 36.2
C (97.1
   HR: 82 (81 - 101) bpm
   BP: 87/51(60) {82/41(50) - 104/60(80)} mmHg
   RR: 13 (9 - 23) insp/min
   SpO2: 100%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 62 Inch
             Total In:
                                                                  5,370 mL
                                                                  1,062 mL
   PO:
                                                                    990 mL
             TF:
   IVF:
                                                                  4,380 mL
                                                                  1,062 mL
   Blood products:
   Total out:
                                                                  2,945 mL
                                                                    545 mL
   Urine:
                                                                  1,345 mL
                                                                    145 mL
   NG:
   Stool:


NPN 1900-0700


FEN: wt=2265g (up 50g). TF=130cc/kg/d of SSC 28 with promod.
Equals 49cc q4hrs, PO/PG. Bottled 25cc with good
coordination, lacks stamina. Requires frequent burping.
Gavaged over 1hr 15min. Abdomen soft, full. +BS, AG stable,
no loops, sm spit X1, voiding and [** **]. On Fe.

[** **]: No contact thus far.

G&D: Temp stable, swaddled in open crib. Alert and active
with cares. Sleeps well between. Bath given.

Resp: In RA. O2sat 94-100%. RR 30-50's. LS clear and equal.
Mild SC rtx. No spells or drifts. On caffeine.


[**2189-12-1**] 8:32 PM
 CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS             Clip # [**Clip Number (Radiology) 31361**]
 CT BRAIN PERFUSION; -59 DISTINCT PROCEDURAL SERVICE
 Reason: stroke, IPH
 Admitting Diagnosis: ACUTE CORONARY SYNDROME
  Contrast: OPTIRAY Amt: 110
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


82 year old woman with sudden onset R weakness L facial droop aphasia


REASON FOR THIS EXAMINATION:


stroke, IPH
 No contraindications for IV contrast
 ______________________________________________________________________________
 PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa WED [**2189-12-2**] 2:29 PM
  1. Complete occlusion of the right M1 segement with no gross evidence of the
  [**Doctor Last Name 34**] white matter differentiation representing an acute infarct.

  2. Perfusion images demontrate a matching decrease blood volume, blood flow
  and increased mean transit time involving the entire right MCA territory.

 ______________________________________________________________________________


FINAL REPORT


INDICATION:


82 year old woman with sudden onset right weakness left facial
 droop aphasia.


COMPARISON:


none.


TECHNIQUE:


Continuous axial CT images were obtained through the brain without
 intravenous contrast material.  Subsequently, rapid axial imaging was
 performed from the aortic arch through the brain during infusion of
 intravenous contrast material.  Images were processed on a separate
 workstation with display of curved reformats, 3D volume-rendered images, and
 maximum intensity projection images. CT perfusion images were also obtained.


FINDINGS:


CT:

 There are bilateral nonspecific periventricular hypodensities. There is a
 focal hypodense lesion in the right basal ganglia likely representing an
 infarct of undetermined age.
 The ventricles, sulci, and cisterns are age appropriate. There is no evidence
 of intracranial hemorrhage or mass. There is no apparent extra-axial
 collection. There are degenerative changes of the spine. The paranasal sinuses
 are clear. There is a right lens replacement.

 The soft tissues are unremarkable. The visualized portions of the lung apices
 are unremarkable. The thyroid gland is normal in appearance. The soft tissues
 of the neck are normal appearing.

 CTA:

 Arch & Neck:
                                                             (Over)

 [**2189-12-1**] 8:32 PM
 CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS             Clip # [**Clip Number (Radiology) 31361**]
 CT BRAIN PERFUSION; -59 DISTINCT PROCEDURAL SERVICE
 Reason: stroke, IPH
 Admitting Diagnosis: ACUTE CORONARY SYNDROME
  Contrast: OPTIRAY Amt: 110
 ______________________________________________________________________________


FINAL REPORT


(Cont)

 There is mild calcification of the aortic arch. The brachiocephalic artery,
 and the right common carotid artery are of normal course and caliber. There is
 mild bilateral bifurcation disease but no significant stenosis. There is
 retropharyngeal course of the left ICA.

 The origin of the right vertebral artery is patent and the right vertebral
 arteries of normal course and caliber. There is a hypoplastic left vertebral
 artery. Bilateral subclavian arteries are normal course and caliber.

 Circle of [**Location (un) 501**]:

 There is an abrupt termination of the left M1 segment.

 The petrous, cavernous, and supraclinoid internal carotid arteries are of
 normal course and caliber. The anterior cerebral arteries are of normal course
 and caliber. The right middle cerebral artery is of normal course and caliber.
 The posterior cerebral arteries are of normal course and caliber. The right
 vertebral artery is dominant and forms the basilar artery. The left vertebral
 artery is hypoplastic and ends as a pica. The major venous structures enhance
 normally.

 Perfusion images demontrate a matching decrease blood volume, blood flow and
 increased mean transit time involving the entire right MCA territory.


IMPRESSION:


1. Complete occlusion of the right M1 segement with no gross evidence of the
 [**Doctor Last Name 34**] white matter differentiation representing an acute infarct.

 2. Perfusion images demontrate a matching decrease blood volume, blood flow
 and increased mean transit time involving the entire right MCA territory.

 Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was present during the scan and review the images with
 the resident within 20 minutes of the image acquisition.


NPN 7 PM- 7 Am

PT stable overnight, continues on SCUF therapy for fuid overload and renal failure, tolerated well, without drop in BP. Reached goal of net negative 5 liters at midnight and this morning pt is additionally net negative 1.7 liters . She is breathing easier and her edema is markedly decreased. Pt able to tolerate room air overnight, 02 sats on room air 93-98 percent, continues to have some DOE when getting out of bed to  commode and back. Morning labs PTT within range, lytes OK, Phos is high and creatinine continues to climb, pt put out only 200 cc last night voiding.  She took her cough med and ambien last night and was able to sleep , she did however remove BP cuff and o2 sat probe at one point and stated that she could not sleep with them on. SHe states she is anxious to get rid of all these wires and would like to remove the heart monitor as well.

Prisma machine is running well and catheter functions ok, however clots continue to appear in the access pressure pod and system was changed after several filter is clotting alarms. We are also flushing the filter Q4-6 hours with saline, but without replacement fluid system is prone to clotting.

A: Pt with cardiomyopathy and copd, fluid overload, now down 77 lbs
since [**5-22**] , feeling better but continues to have ARF.

P: Continue SCUF therapy as tolerated by pt hemodynamics, follow Labs,
I/O, consider phosphate binders, OOB to chair.


Sinus rhythm. Probable left atrial abnormality. Right bundle-branch block.
Since the previous tracing of [**2106-1-15**] right bundle-branch block is now present.


Respiratory Therapy
Pt remains orally intubated on PSV.  Currently +5PSV/+5PEEP.  BLBS slightly coarse at times, suctioned for small amounts of thick white secretions from ETT and copious amounts of clear oral secretions.  SpO2 remained 90s.  Travelled to and from CT for scan of head w/out incident. ETT remains secure/patent & in good position.  See resp flowsheet for specific vent data.

Plan: maintain current support


[**Hospital Ward Name **] 4 ICU nursing progress note:
 Respiratory: Remains intubated and vented...PS 15/ 5 peep..decreased to PS 10..shortly after had increased rr 40's..TV down to 200's..Placed back on 15/5. Small amt of secretions..sent for cultures.. Pt seems to be more comfortable with left side down. (better TV/lower rr)
 Cardiac: Several runs of ??af..hr 140-160 for brief periods..does drop bp into the 70's with this. Very frequent episodes of pacs and occassional pvc. K repleted. BP 80-110/50-60..no change in captopril dose.
 Volume status: Resumed Lasix gtt early am.. Pt i/o pos. Currently on 2mgm hr..continueing to follow..keep neg by 500-1000cc.
 GI: TF continue at goal..several episodes of small-mod amts loose stool. ob -. Free water deficit..started free water boluses q6hrs.
 GU: Output slowly picking up..
 ID: Afebrile..vanco added..awaiting sputum culture.
 Lytes: Pt alkalotic..??from Lasix gtt..started on KCL gtt 10meq/hr..checking lytes q6hrs.
 Neuro: On versed gtt at .5mgm..prn boluses with turning.
 Endo: Insulin gtt remains off..bs at 12n was 40..given 1 D50..repeat bs 119..want BS below 120.
 Social: Pts daughter and wife in to visit..able to communicate by signing..pt awake and alert at the time. All updated on condition.


Nursing Progress Note
Events: Pt had CT scan of abd today b/c of slighty falling hct and firmly distended abd. Results pending.

Neuro: Pt alert, intermittently dozing. At times appearing anxious and restless. Pt recieved 5mg IV haldol with good effect. PERRLA, 3mm, brisk. Tracking with eyes. Pt does not follow verbal commands. Spontaneous movement with all extremeties. Purposeful movements noted towards mouth when recieving mouth care, and towards face to scratch. Pt grimacing with turns and dsg changes. 2tabs percocet given with fair effect.

CV: NSR, rare PAC's. HR 60-80's, down to 50's and up to 90's at times. SBP 110-160's. +PP. 3+ edema to LLE. Anasarca. K repleted as ordered. Pt finished 2 units PRBC, hct reponding appropriately.

Resp: No vent changes made today. Pt cont on c-pap [**2125-4-18**]. Last abg wnl. Sats 96-100%. RR labile, 8-29 bpm. LSCTAB. Pt has strong cough and weak gag. Sx'd several times for mod amts thick clear secretions.

GI: Abd firmly distended, tender to palpation. +BS. Pt had one lrg, and several small BM's this shift. TF turned off before CT scan, g-tube now clamped.

GU: Foley draining adequate amts clear amber urine. UOP >40 ml/hr.

[**Month/Day/Year 505**]: FSBS per SS. Adequately covered by SS.

ID: Tmax 101.3. Tylenol given. Pt cont on meropenum.

Skin: Pt has several serous oozing skin tears and blisters on L arm and torso, all covered with dsg's. W/D dsg to open area of incision, changed, site granulating with minimal s/s drainage. Stage 2 to coccyx, desetin applied.

Social: Daughter spoke with HO [**Name (NI) 1761**], pt consented for blood products. Pts companion [**Doctor First Name 4302**] also visited today.

Plan: Follow up CT results. Haldol prn for agitation. Wean vent as tol. Maintain skin integrity. Cont to support pt and family.


Sinus tachycardia. Left atrial abnormality. Right bundle-branch block. Frequent
atrial ectopy. Compared to the previous tracing of [**2174-2-22**] no diagnostic interim
change.


Impaired Skin Integrity
   Assessment:
   Perineum reddened and sore to touch as patient moves about in the bed
   when attempting to clean.
   Incontinent of loose brown stool.
   Action:
   Turned q2hrs.
   Perineum area cleansed with warm soap and h20.
   Nystatin powder applied followed by desitin.
   Flexiseal placed
   Response:
   Perineum continues to be reddened due to being incontinent of stool.
   Desitin cream  to reddened area.
   Plan:
   Continue to examine skin and document.
   Continue to apply nystatin powder.
   Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway
   Clearance, Cough)
   Assessment:
   Trach intact
   Suctioned for thick white/yellow sputum
   O2sat 96-100%
   Lungs rhonchous
   On cpap [**5-29**]
   Action:
   Suction prn
   Turned q2hrs
   Oob to chair for 2 hrs
   Antibiotics as ordered.
   Trach collar applied at 1500
   Response:
   Resp status  unchanged.
   Currently breathing 20-24/min with sats >96%
   Plan:
   Monitor resp status closely
   Rest on cpap
   Update family  on pt
s condition and progress.
   ------ Protected Section ------
   Continues on lasix gtt a 2mg with excellent diuresis.  Currently on 1mg
   lasix,  Neg 1.5 liters
   ------ Protected Section Addendum Entered By:[**Name (NI) 461**] [**Last Name (NamePattern1) 10192**], RN
   on:[**2140-10-11**] 17:36 ------


Attending note
DAy of life 13 PMA 28 [**6-19**]
SIMV 25/6 rate 28 FiO2 23-26% RR 30-50 on caffeine an vit A CBG 7.26/55 suctioned for mod cloudy
no spells but drifts in sats
HR 150-160 BP 67/30 mean 44
weight 935 no change on 160 cc/kg/day enteral feeds at 70 cc/kg/day adv 10 cc/kg/day [**Hospital1 **] D stick 87
no spit
UO 4.3 cc/kg/hr and trace mec stool
on servo stable temp

Imp-infant making slow progress
RESP-will wean the ventilator as tolerated. will recheck a gas yesterday
FEN-will decrease the total fluids to 150 cc/kg/day. Will continue to advance enteral 10 cc/kg/day. Will recheck lytes in am
GI-will recheck bili in the am


NEonatology-[** 13**] Progress Note

PE: [**Known lastname **] remains in her isolette, nested  on 22/6 X26 bbs sl cse=, rrr s1s2 no murmur, thoracotomy incision slightly erythemia (reportedly improved) abd soft nontender, V&S, afso, gavage and picc line in place, dsg secure

See attending note for plan


NPN 0700-1900
Infant had one spell this shift; HR decreased to 52 with desat to 78%; during sleep and self resolved on own.


Neonatology Attending

Day 6  PMA 37 [**1-18**] wks

Remains in RA.  RR 60-70s.  HR 120-160s.  BP mean 54.  No murmur.  Bilirubin 9.3.  Weight 1895 gms (+10).  On Enfamil at 140 cc/kg/d.  Requiring gavage supplement.  Stable temperature in open crib.  NAS [**5-18**] on NOS current dose.  Mother in yesterday.

Abstinence better controlled.  Will continue to monitor.  Starting to gain weight- will increase to 150 cc/kg/d today.  Parents up to date.


Add: Pt oriented to self and knows she is in hospital but unable to state which one "[**Hospital6 **]".
+ confusion and drowsiness this early evening.


RN progress note
Neuro: AAO x 3; calm & coop. No focal deficits.

CV: NSR, no VEA. CVP 5-9. BPS.90, MAPS > 60, no pressors.  A/V wires C/S; generator off.

Pulm: dim bases; CTAb. O2 2L/NP sats > 95%. Good CDB, fair IS; cough prod thick white.  CT s/s drng, 10-30cc/hr; no leak.

GI: nauseous intermittently; med w/ reglan 10mg IV x 1. BS hypo; no BM. Tol ice chips.

GU: UOP 30-60cc/hr. Onset light brown vaginal flow.

MS/derm: sternum stable. Chest wounds C/D, old drng. C/O persistent mid scapular pain; effective analgesia w/ MS 2 mg q4-hr.  SQ crepitous right clavicular area.

Endo: BG wnl.

Heme: H/H: 25/8; Plts 287

Chem: K+ repleted, otherwise WNL.

ID: afebrile; Vancomycin q 12h. WBC 21.5

A: ASD / anamolous pulm vein repair, stable hemodynamics; elevated WBC, absence of fever, sx. Sluggish GI. Onset menses.

P: OOB, aggressive bronchial hygeine. ?d/c cordis. F/U WBC. Transfer


PATIENT/TEST INFORMATION:


Indication:


Left ventricular function. Shortness of breath.
Height: (in) 68
Weight (lb): 152
BSA (m2): 1.82 m2
BP (mm Hg): 162/70
HR (bpm): 80
Status: Inpatient
Date/Time: [**2172-1-6**] at 14:00
Test: TTE (Congenital, complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


This study was compared to the prior study of [**2171-12-6**].


LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)
with >55% decrease during respiration (estimated RAP (0-5mmHg).

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global
systolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal descending aorta diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No valvular
AS. The increased transaortic velocity is related to high cardiac output.
Trace AR.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA
systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with
physiologic PR.

PERICARDIUM: Small pericardial effusion. Effusion circumferential.

Conclusions:
The left atrium is mildly dilated. The estimated right atrial pressure is 0-5
mmHg. A small secundum type atrial septal defect is suggested, but could not
be confirmed. There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size and free wall motion are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is not present.
There is no valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is a small circumferential pericardial effusion without
evidence of hemodynamic compromise.


IMPRESSION:


Mild symmetric left ventricular hypertrophy with preserved global
and regional biventricular systolic function. High velocities across the
pulmonic and aortic valves c/w high output syndrome (anemia, fever,
thyrotoxicosis; does the patient have a retained AV-fistula for dialysis).
Compared with the prior study (images reviewed) of [**2171-12-6**], the overall
findings are similar (an atrial septal defect is not as well defined on the
current study, but images are not as optimal and likey due not reflect a true
change).

CLINICAL IMPLICATIONS:
Based on [**2171**] AHA endocarditis prophylaxis recommendations, the echo findings
indicate prophylaxis is NOT recommended. Clinical decisions regarding the need
for prophylaxis should be based on clinical and echocardiographic data.


[**2181-8-17**] 8:44 PM
 CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN          [**Name Initial (PRE) 7**] # [**Clip Number (Radiology) 66804**]
 Reason: ?line placement, PTX
 Admitting Diagnosis: SUBARACHNOID HEMORRHAGE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


[**Age over 90 **] year old woman s/p R subclavian line


REASON FOR THIS EXAMINATION:


?line placement, PTX
 ______________________________________________________________________________


FINAL REPORT


PROCEDURE:


Chest port line placement.


REASON FOR EXAM:


Exclude pneumothorax.

 ET tube, pacing wires and NG tube are unchanged.  New right central venous
 catheter tip lies at the cavoatrial junction.  Left lower lobe atelectasis is
 unchanged.  Lungs are otherwise fully expanded and clear with a minimal right
 pleural effusion stable.  Cardiomediastinal silhouette is unchanged.


IMPRESSION:


Satisfactory placement of a new right central venous catheter with no
 pneumothorax. Stable small right pleural effusion and left lower lobe
 atelectasis.


TITLE: CRITICAL CARE
   Present for the key portions of the resident
s history and exam. Agree
   substantially with assessment and plan as outlined during
   multidisciplinary rounds this morning. Immediately distressed when vent
   support reduced
   99.7        94         94/41
   Chest
 mid insp crackles
   CV [**1-27**] holosyst m
   Adb
 soft w/o tenderness
   WBC 14.8
   Very difficult.  She decompensates with every effort to wean. NIF is
   -15 although not a max effort. She is acting as though she is weak.
   Will ask Neuromuscular to see.  We are pushing to remove fluid,
   particularly in light of recent cardiac event. BP remains v labile.
   Will switch back to CVVH if we cannot remove fluid with HD.  [**Month (only) 60**] be
   headed to trache.
   Time spent 45 min
   Critically ill


[**Last Name (LF) 8599**],[**First Name3 (LF) 8600**] G.                    [**Hospital Unit Name 8601**]                  [**2200-9-18**]  1:45 PM
 UNILAT UP EXT VEINS US RIGHT                                    Clip # [**Clip Number (Radiology) 7807**]
 Reason: DVT
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


87 year old woman with a-fib admitted for pneumonia.  With increased R arm
  swelling.


REASON FOR THIS EXAMINATION:


DVT
 ______________________________________________________________________________
                                  PFI REPORT
 No deep vein thrombosis seen.  Thrombus identified in the two superficial
 veins, the right basilic and the right cephalic.


Chief Complaint:  Right leg pain, witnessed apnea.
   HPI:
   51 yo F with obesity and OSA admitted after left total knee replacement
   for monitoring after witnessed apneic episodes in the PACU.
   .
   On the day of admission, the patient underwent uncomplicated left total
   knee replacement. Intra-op and post-op vitals were remarkable for HR
   90's BP 120-160/60-80. The patient had a single episode of RR 6-8 with
   O2 sat 92-95%. She was sleepy and arousable but with episodes of apnea.
   She was placed on an autoset CPAP for likely sleep apnea and due to
   persistent episodes of apnea, she was transferred to the ICU for
   further monitoring. In the PACU, she received morphine 7.5mg IV,
   dilaudid 1.6mg IV, phenergen 6.25mg, naproxen 500mg, gabapentin 300mg,
   clonazepam 2mg and cefazolin 1g IV as well as albuterol and ipratropium
   nebs.
   History obtained from [**Hospital 85**] Medical records
   Allergies:
   Erythromycin Base
   Unknown;
   Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)
   Hives;
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Other medications:
   Home Meds:
   - Albuterol inhaler three times a day
   - Pantoprazole 40mg Daily
   - Ipratropium/albuterol inhaler 2 puffs fours times daily as needed
   - Fluticasone 220mcg 2 puffs twice daily
   - Tylenol with codeine
   - Acyclovir 800mg three times a day as needed
   - Clonazepam 1-2mg as needed at bedtime
   - MVI
   - Iron pill
   - Vitamin C 1000mg Dialy
   Past medical


history:


Family


history:


Social


History:


- DJD of the left knee, post-traumatic
   - Medial meniscal tear of the right knee
   - Asthma
   - Obesity, OSA
   - Sinsuitis s/p endoscopic  anterior  and  posterior ethmoidectomies,
   right  sphenoidotomy, maxillary sinus  antrostomies, repair of deviated
   septum ([**2145**])
   - Lymphocytic vasculitis of skin
   Non-contributory
   Occupation:


[**2152-8-13**] 5:15 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 25372**]
 Reason: please evaluate for improvement in intrapulmonary process
 Admitting Diagnosis: BLUNT TRAUMA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41M w/ h/o EtOH and opiate abuse s/p MCC sustaining rib fxs, left scapular fx.
  Now with multifocal pneumonia.


REASON FOR THIS EXAMINATION:


please evaluate for improvement in intrapulmonary process
 ______________________________________________________________________________


FINAL REPORT


CHEST RADIOGRAPH


INDICATION:


Rib fractures, left scapular fracture, multifocal pneumonia,
 evaluation of interval change.


COMPARISON:


[**2152-8-12**].


FINDINGS:


As compared to the previous radiograph, there is no relevant
 change.  Unchanged monitoring and support devices.  Unchanged retrocardiac
 atelectasis and right basal atelectasis as well as left perihilar atelectasis.
 No newly occurred focal parenchymal opacities.  No pleural effusions.  Normal
 size of the cardiac silhouette.


Demographics
   Day of intubation:
   Day of mechanical ventilation: 1
   Ideal body weight: 80.7 None
   Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg
   Airway
   Airway Placement Data
   Known difficult intubation: No
   Procedure location:
   Reason:
   Tube Type
   ETT:
                   Position: 23 cm at teeth
                   Route: Oral
                   Type: Standard
                   Size: 7.5mm
   Cuff  Management:
                   Vol/Press:
                                   Cuff pressure: 25  cmH2O
                                   Cuff volume:   mL /
                   Airway problems:
                   Comments:
   Lung sounds
   RLL Lung Sounds: Diminished
   RUL Lung Sounds: Clear
   LUL Lung Sounds: Clear
   LLL Lung Sounds: Diminished
   Comments:
   Secretions
   Sputum color / consistency: Bloody  / Thick
   Sputum source/amount: Suctioned / Moderate
   Comments:
   Ventilation Assessment
   Level of breathing assistance: Continuous invasive ventilation
   Visual assessment of breathing pattern: Normal quiet breathing
   Assessment of breathing comfort: No response (sleeping / sedated)
   Invasive ventilation assessment:
   Trigger work assessment: Not triggering
   Plan
   Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,
   Reduce PEEP as tolerated, Adjust Min. ventilation to control pH
   Reason for continuing current ventilatory support: Sedated / Paralyzed,
   Cannot manage secretions, Underlying illness not resolved
   Bedside Procedures:
   ABG puncture (1400)
   Comments:


NICU NPN 0700-1900


RESP: [**Known lastname 1617**] remains on NC O2, 100%, 75-150cc this shift. RR
40-70's. LS clear and equal. Mild SC retractions. UAC noted.
No [**Known lastname 482**], no bradys. On [**Known lastname 42**], caffeine, KCl. Continue to
monitor respiratory status, wean O2 as tolerated.

G/D: [**Known lastname 1617**] remains in an open crib, stable temps. [**Known lastname 25**] and
active with cares, sleeping well b/w. Learning to bottle.
Brings hands to face, loves pacifier. Waking prior to some
cares this shift. Repeat eye exam tomorrow - continues to
receive eye drops as ordered. Continue to support growth and
development.

[**Known lastname **]: Mom called x1 this shift. Stated that they will be
in tonight at 8pm. Updated on status. Continue to support
and update.

FEN: TF=140cc/k/d, PE30 with Promod, 69cc q 4 hours. Infant
alt po/pg this shift, bottling full volumes at 0800 and 1600
feeds. Small spit x1, minimal aspirates. Abdomen soft, +BS,
no loops. Voiding, no stool this shift. On Vit E and Fe.
Continue per plan, encourage po feeds as tolerated.


67 y/o M h/o CAD and s/p MI in [**2123**] w/o successful intervention, VF
   arrest.  ? Inf/lat changes on EKG. Transferred to [**Hospital1 **] from [**Hospital 632**] hosp
   for revascularization. Cath 2VD, unable to open LCx. Labile BPs in lab,
   sent to CCU, unresponsive on NGT gtt.
   Cardiac arrest
   Assessment:
   Remains on arctic sun protocol, goal Temp 34 C.  SBP less labile
   120-150 by femoral a-line, ~ 10 points less by cuff.  HR 40
s-50
s SB
   at rest, up to 60 SB with repositioning.  Occ multifocal PVC
   Satisfactory ABG this am.
   Action/Response:
   IV NTG weaned to off, amiodarone  and heparin gtt
s turned to off.
   Echo done, EF 35% by report. Sent for head and neck CT
cervical spine
   ok, but collar remains in place until pt is awake and can reassess
   clinically.  Remains on fentanyl/versed gtts and cistatracurium.  No
   movement observed spontaneously or to stimulation.  Pupils equal and
   reactive to light. No seizure activity noted.   Continuous EEG applied
   X 48 hours as part of cooling protocol.  Arterial sheath pulled  by CCU
   fellow with hemostasis @ 1530.  No bleeding @ site, pulses remain
   weakly palpable.  Feet pink, cold.  Capillary refill ~ 4 seconds.
   FiO2 weaned to 40%-550-18, PEEP 5.  ABG 7.43/40/74
to remain on current
   vent settings.
   Plan:
   As per rounds, begin re-warming @ [**2116**].  Wean paralytic.  Monitor for
   seizure activity.  Monitor femoral site, assess distal perfusion.
   Monitor for Hemodynamic/ HR changes with rewarming.
   Hyperglycemia
   Assessment:
   BS 350 @ 0800.
   Action/Response:
   Discussed am BS with Dr. [**Name (NI) **], pt given an additional 5 units of regular
   insulin (to receive total sliding scale dose while NPO).  BS 341 @
   1400.  Discussed with Dr. [**First Name (STitle) 335**], sliding scale tightened and frequency
   increased to q 6 hours.
   Plan:
   As per Dr. [**First Name (STitle) 335**], [**First Name3 (LF) 116**] reassess total insulin dose this evening, ? begin
   a basal level of insulin.
   Impaired Skin Integrity
   Assessment:
     R lower leg dressing site intact.  Pt on paralytic [**Doctor Last Name 23**], no pressure
   sites noted.
   Action/Response:
   DSD over IO site on R lower leg.  Pt repositioned from side to side.
   Heels suspended off of mattress.   Aloe vesta cream to pressure
   points.  [**Location (un) 239**] J collar care done.
   Plan:
   Continue to reposition, heels off of bed.  [**Location (un) 239**] collar care.  Monitor
   IO site.
   Social:  wife and daughter in to visit.  Updated on multidisciplinary
   [**Name6 (MD) **] by RN and MD.
   Access:  TLC, site no longer oozing from stitches, site remains soft
   but ecchymotic. PIV X2.


3. TF min 140cc/k/d Bm/E24 56cc q4h, taking 45-60cc po well,
abd soft, voiding, no stool so far this shift, no spits, on
ferinsol A: taking po well P: continue present care.
5. temp stable swaddled in open crib with sisters, waking
for most feedings, active and [** 29**] with cares, for HUS wed,
possible dc to home on wed.
6. Mom here at 12n, back at 1600 with [** 45**], brought in car
seats, Mom pumping breast milk, very [** **] and independent
in cares, formula prep and safe travels reviewed.


[**2105-6-30**] 6:24 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 30971**]
 Reason: intubated patient
 Admitting Diagnosis: CONGESTIVE HEART FAILURE
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for iv
   access,heparin and antibiotics.


REASON FOR THIS EXAMINATION:


intubated patient
 ______________________________________________________________________________


FINAL REPORT


AP CHEST 5:31 A.M. [**6-30**]


HISTORY:


Embolic stroke.  PICC line.


IMPRESSION:


AP chest compared to [**6-27**] through 21:

 Left lower lobe atelectasis persists.  Tip of the right PIC line is partially
 obscured, but passes at least as far as the upper SVC.

 Tip of the ET tube at the upper margin of the clavicles is at least 6 cm from
 the carina, with the chin partially flexed.  This is 3 cm above optimal
 placement.  NG tube passes below the diaphragm and out of view.  Lungs grossly
 clear.  Heart size normal.  No pneumothorax.


Chief Complaint: 86 year old female with afib, CHF, DM2, CKD, and
   recurrent UTIs who presents with UTI and likely pyelonephritis.
   24 Hour Events:
   - diuresed - didn't have great output to 80 IV lasix. gave 160 in PM
   - started heparin gtt for subtherapeutic INR
   - called out
   Allergies:
   Penicillins
   Unknown;
   Last dose of Antibiotics:
   Meropenem - [**2111-2-21**] 05:42 AM
   Infusions:
   Heparin Sodium - 700 units/hour
   Other ICU medications:
   Furosemide (Lasix) - [**2111-2-20**] 12:23 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  [**2111-2-21**] 07:19 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**12**] AM
   Tmax: 36.7
C (98.1
   Tcurrent: 36.2
C (97.1
   HR: 95 (90 - 112) bpm
   BP: 111/76(85) {86/42(53) - 148/95(104)} mmHg
   RR: 12 (12 - 25) insp/min
   SpO2: 97%
   Heart rhythm: AF (Atrial Fibrillation)
   Wgt (current): 62 kg (admission): 61.8 kg
             Total In:
                                                                  1,169 mL
                                                                    285 mL
   PO:
                                                                    880 mL
                                                                    100 mL
   TF:
   IVF:
                                                                    289 mL
                                                                    185 mL
   Blood products:
   Total out:
                                                                  1,585 mL
                                                                    700 mL
   Urine:
                                                                  1,585 mL
                                                                    700 mL
   NG:
   Stool:


[**2142-9-13**] 5:37 AM
 SHOULDER 1 VIEW RIGHT PORT                                      Clip # [**Clip Number (Radiology) 34437**]
 Reason: s/p MVA,  need film of RIGHT SHOULDER,  , PT in sicu/ctic on
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


49 year old woman with

  please page [**Numeric Identifier 3941**] with results


REASON FOR THIS EXAMINATION:


s/p MVA,  need film of RIGHT SHOULDER

  PT in sicu/ctic on west
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Status post MVA. Right shoulder pain.

 Single AP internal rotation view of the shoulder. No fracture is detected
 about the shoulder on this limited single view. No obvious glenohumeral joint
 dislocation, though additional views would be required to confirm this. AC
 joint within normal limits.


Neonatology - NP Physcial Exam
Awake and [** 29**] with cares, temp stable in open crib. Remains in nasal cannula O2 200-400cc 80% to keep O2 sats greater than 94. BS clear and equal with moderate intercostal/subcostal retractions, color pink. RRR, soft murmur on auscultation, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Umbilical hernia soft and easily reducable. Normal female genitalia. Without rashes. Good tone, AFSF, PFSF, +suck, +[**Location (un) 368**], +plantar reflexes. Please see attending neonatologist note for detailed plan of care.


[**2162-5-24**] 10:58 AM
 SHOULDER [**2-23**] VIEWS NON TRAUMA LEFT                              Clip # [**Clip Number (Radiology) 97825**]
 Reason: eval for fracture
 Admitting Diagnosis: ETOH WITHDRAWAL
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41 year old man with left sided shoulder pain


REASON FOR THIS EXAMINATION:


eval for fracture
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


41-year-old male with left-sided shoulder pain.


COMPARISON:


None.

 LEFT SHOULDER, THREE VIEWS:  Deformity of the humeral head likely represents
 old healed fracture and avulsion of the greater tuberosity.  A healed fracture
 of the distal left clavicle is also observed.  There is no acute fracture or
 dislocation.  A 5-mm nodular density in the left upper lung likely represents
 a calcified granuloma.


IMPRESSION:


No acute fracture. Evidence of prior healed left humeral and
 clavicular fracture.


[**Last Name (LF) **],[**First Name3 (LF) **] R.                     [**Doctor First Name 239**] SICU-B                [**2160-8-14**]  5:46 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 93629**]
 Reason: evaluate for intracranial process given encephalopathy, [**Doctor Last Name **]
 Admitting Diagnosis: HYPONATREMIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


51F with liver cirrhosis with mental status change, encephalopathy?


REASON FOR THIS EXAMINATION:


evaluate for intracranial process given encephalopathy, change in mental status
 No contraindications for IV contrast
 ______________________________________________________________________________
                                  PFI REPORT
 1.  No acute intracranial process.

 2.  Aerosolized secretions and mucosal thickening within the right sphenoid
 sinus.


TITLE:
   MICU ATTENDING ADDENDUM
   I saw and examined the patient, and was physically present with the ICU
   team for the key portions of the services provided. I agree with the
   note above, including the assessment and plan.
   Remains on vent with intermittent cuff leak. He had what appeared to be
   another seizure yesterday and an EEG is being performed.
   Exam notable for: afebrile, HR 101, 100/65, 93%
   AC 14/550/5/0.5
   Trached , opening eyes though unresponsive
   Lungs rhonchorous
   Hrt rrr
   Abd benign
   Extreme right arm splinted
   CXR trached, bilateral effusions, RIJ in place
   He will continue to be supported on the vent. His seizures are being
   evaluated by EEG currently and we await neurology
s recommendations.
   For now, his current anti-seizure meds will be continued and ativan
   will be used to break active seizures.  He is on meropenem for his
   pseudomonas pneumonia. Hypernatremia will be treated will H2O. He has
   significant bilateral effusions and further diuresis will be attempted.
   Continue the wrist splint.


Impaired Skin Integrity
   Assessment:
   Coccyx reddened, friable tissue, excoriated at sacrum.  Douderms intact
   on ankles.
   Action:
   [**Doctor First Name **]-air bed. Turned q 3-4 hrs. Criticaid->coccyx. Multipodus boots.
   Response:
   No change
   Plan:
   Skin care, Criticaid- coccyx. Duoderm ->ankles. Turn q 2-4 hrs.
   Nutrition recommendations.
   Alteration in Nutrition
   Assessment:
    G-tube site is reddened, very foul smelling. Wound Cx pending
   Action:
   NPO for now. Meds only via g-tube.
   Response:
   Decrease in oral secretions overnight. Hypernatremia resolved.
   Plan:
   NPO until further notice. ? change g-tube to J-tube as pt appears to
   have been aspirating from tube feeds.
   Pneumonia, aspiration
   Assessment:
   Lungs rhonchorous throughout. Suctioned several times for copious thick
   tan secretions. Sats 100%.
   Action:
   Nasally intubated on CPAP settings. Turn q 3-4 hrs. Suctioning.
   Antibx.  Mouth care. HOB ^ 30. NPO.
   Response:
   WBC decreasing
now 14. Continues with low grade temp. Pt is more
   alert, responsive, following commands.
   Plan:
   Pulmonary hygiene, VAP protocol. Antibx. CXR pending this AM. Follow
   fever curve. NPO d/t aspiration risk. Cultures pending.


Subjective
   Unable to speak with patient due to intubation
   Objective
   Height
   Admit weight
   Daily weight
   Weight change
   BMI
   182.8 cm
   90 kg
   n/a
   27
   Ideal body weight
   % Ideal body weight
   Adjusted weight
   Usual body weight
   % Usual body weight
   80.7
   111%
   n/a
   Diagnosis: Altered Mental Status
   PMH : Afib, HTN, Skin CA
   Food allergies and intolerances:  n/a
   Pertinent medications: Fentanyl, Midazolam, Lanzoprazole, Heparin, 60
   mEq KCl, 1000 mL NS x 2, Insulin 30.8 units
   Labs:
   Value
   Date
   Glucose
   99 mg/dL
   [**2184-4-14**] 09:54 AM
   Glucose Finger Stick
   161
   [**2184-4-14**] 09:00 AM
   BUN
   24 mg/dL
   [**2184-4-14**] 09:54 AM
   Creatinine
   1.4 mg/dL
   [**2184-4-14**] 09:54 AM
   Sodium
   142 mEq/L
   [**2184-4-14**] 09:54 AM
   Potassium
   4.0 mEq/L
   [**2184-4-14**] 09:54 AM
   Chloride
   109 mEq/L
   [**2184-4-14**] 09:54 AM
   TCO2
   22 mEq/L
   [**2184-4-14**] 09:54 AM
   PO2 (arterial)
   160 mm Hg
   [**2184-4-14**] 04:32 AM
   PCO2 (arterial)
   40 mm Hg
   [**2184-4-14**] 04:32 AM
   pH (arterial)
   7.43 units
   [**2184-4-14**] 04:32 AM
   CO2 (Calc) arterial
   27 mEq/L
   [**2184-4-14**] 04:32 AM
   Albumin
   3.0 g/dL
   [**2184-4-14**] 09:54 AM
   Calcium non-ionized
   7.6 mg/dL
   [**2184-4-14**] 09:54 AM
   Phosphorus
   2.4 mg/dL
   [**2184-4-14**] 09:54 AM
   Magnesium
   2.4 mg/dL
   [**2184-4-14**] 09:54 AM
   ALT
   14 IU/L
   [**2184-4-14**] 09:54 AM
   Alkaline Phosphate
   65 IU/L
   [**2184-4-14**] 09:54 AM
   AST
   41 IU/L
   [**2184-4-14**] 09:54 AM
   Total Bilirubin
   0.4 mg/dL
   [**2184-4-14**] 09:54 AM
   WBC
   8.1 K/uL
   [**2184-4-14**] 09:54 AM
   Hgb
   10.1 g/dL
   [**2184-4-14**] 09:54 AM
   Hematocrit
   29.2 %
   [**2184-4-14**] 09:54 AM
   Current diet order / nutrition support: Diet: NPO
   Tube feeding: Replete with Fiber @ goal of 50 mL/ hour (1200 kcals and
   74 g protein)
   GI: abd. soft, distended, (+) bs
   Assessment of Nutritional Status
   At risk for malnutrition
   Pt at risk due to: NPO, altered mental status, intubated
   Estimated Nutritional Needs
   Calories: 2250-2700 (25-30 cal/kg)
   Protein: 108-135 (1.2-1.5 g/kg)
   Fluid: per team
   Estimation of previous intake: Unknown
   Estimation of current intake: Inadequate
   Specifics:
   77 YO male admitted from outside hospital for further management of
   altered mental status. Patient was intubated and sedated at outside
   facility PTA at [**Hospital1 5**] due to his delirium.  CT was negative for PNA, UA
   consistent with infection. Noted decreased BP and UOP. Plans are for
   empiric coverage for meningitis while awaiting LP today.  Nutrition
   consult received regarding tube feeding recommendations. Current tube
   feeding regimen is underfeeding patient.  Per discussion with RN, plans
   are to initiate enteral feedings after LP. Would recommend alternate
   enteral formula to help patient meet his estimated energy needs. Noted
   elevated FSBG, low phos and calcium.
   Medical Nutrition Therapy Plan - Recommend the Following
   Multivitamin / Mineral supplement:  in tube feed
   Tube feeding / TPN recommendations:
   -  Initiate Fibersource HN @ 10 mL/hour, advance by 10 mL q4h or as
   tolerated by patient to goal of 70 mL/hour + 20 g BP to provide 2087
   kcals and 106 g Protein
   - Monitor tube feeding tolerance via residuals, hold if >200 mL
   - Flush with 150 mL of free water q6h
   - Monitor FSBG, continue with insulin coverage as you are
   Monitor electrolytes PRN


Impaired Skin Integrity
   Assessment:
   Pt w/ multiple blisters and open sloughing old blistered areas along
   both arms. Large areas noted over bilat elbows. Oozing serous dng. Area
   lat to rt groin line dsg of large skin tears area. Pt w/ grossly
   edematous extrems, skin taught.  Back, coccyx intact
   Action:
   Dsg changes done. Covered w/ aquacel and kerlex.
   Response:
   Dsg d/I at present
   Plan:
   Cont dsg change as needed.
   ? skin care consult [**8-24**]
   Wound dehiscence
   Assessment:
   Left leg wound w/ open areas x2. dark tissue in wound noted. Min
   serosang dng. Both sides of inc w/ reddened (bldy) firm areas along
   length of incision
   Action:
   w-d dsg change
   vascular team assess wound this am
   heparin d/c (after team speaking w/ cardiology)
   transfused w/ 2 unit prbc today
   Response:
   Stable day.
   Plan:
   Dssg change [**Hospital1 **] and prn
   Monitor hct
   Transfuse as ordered.


CONDITION UPDATE
D.FEBRILE TODAY TO 101.7 DESPITE TYLENOL,SR-ST ON LOPRESSOR,BP STABLE WITH MAP >70 DESPITE LOWER FILLING PRESSURES (PCWP17-13) DUE TO CONTINUOUS DIURESING ON LASIX DRIP AT 3MG/HR.18 HR FLUID BALANCE = NEG 1500.GOAL FOR 24HR BALANCE=-2L.
 ? ACCURACY OF CCO CATH DUE TO SQI CODE OF 4..SVO2 AS HIGH AS 85 AND CO CLIMBING TO 9 DESPITE NO OTHER CHANGES IN PANUMBERS AND RECALIBRATION.
 FENTANYL WEANED DOWN TO 150MCQ WITH PT EASIER TO AROUSE AND SPONTANEOUS RESPIRATIONS.THUS VENT CHANGED TO C-PAP5 WITH CURRENTLY 5 IPS..STV=600,RR=18 AND O2 SAT=96.SXED FOR MINIMAL WHITE SECRETIONS.
 A.? DECREASE LASIX DRIP ONCE 24 HR GOAL REACHED..? INCREASE IPS FOR SLEEP TONITE.?FURTHER DECREASE IN FENTANYL DRIP.
R.PT TOLERATING STEADY SLOW DIURESIS WELL.


[**2133-4-13**] 2:25 PM
 PICC LINE PLACMENT SCH                                          Clip # [**Clip Number (Radiology) 48476**]
 Reason: PLEASE PLACE PICC LINE, PANCREATIC CA
  Contrast: OPTIRAY Amt: 10
 ********************************* CPT Codes ********************************
 * [**Numeric Identifier 993**] REPOSITION CENTRAL VENOUS CATH  [**Numeric Identifier 511**] FLUORO 1 HR W/RADIOLOGIST        *
 * [**Numeric Identifier 59**] CHEST AP ONLY                                                          *
 ****************************************************************************
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


82 year old woman with ca s/p Whipple


REASON FOR THIS EXAMINATION:


PLease place PICC line
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Status post whipple procedure and PICC placement by IV team,
 terminating at the junction of the right subclavian and jugular vein.  Needs
 reposition.

 RADIOLOGISTS PERFORMING THE


PROCEDURE:


Drs.  [**Last Name (STitle) 1890**] and [**Name5 (PTitle) 63**].  Dr. [**Last Name (STitle) 63**],
 the staff radiologist, was present and supervised the entire procedure.


TECHNIQUE:


The patient was put in a supine position on the angiographic
 table.  The external portion of the right arm PICC was prepped and draped in
 the usual sterile fashion.  A small amount of contrast was injected through
 the PICC, demonstrating venous valve immediately central to the tip of the
 PICC.  Reflux was demonstrated into the right subclavian vein.  A 018 glide
 wire was then advanced through the PICC.  Under fluoroscopic guidance, the
 wire and the catheter were advanced further into SVC.  A post procedure chest
 radiograph was performed, demonstrating the tip of the PICC in the SVC.


IMPRESSION:


Successful repositioning of the PICC, currently terminating in
 the SVC.  Ready for immediate use.


Respiratory Care Note
Infant remains on NCPAP +6, 25-29% mostly - BS clear, RR's 40's-50's - mod oral secretions, 1 spell thus far this shift  - on caffeine, continue to monitor.


NPN 0700-1900


RESP: Received infant in prong CPAP 5 21%, trialed off - has
remained in RA since. LS C/=, mild IC/SCR. No spells or
desats.

FEN: Remains NPO, D10 infusing via PIV. D/S stable. Abdomen
soft/round, good bs. V&S (mec stool).

G/D: Temp stable nested on servo warmer. Swaddled infant
w/second cares, but got cold and needed to be placed back
under warmer. A&A w/cares, starting to suck on pacifier for
comfort.

[** **]: Both [** **] and family in to visit several times
throughout shift. Updated by this RN, asking lots of
appropriate questions. Plans to visit for nest cares.

SEPSIS: Continues on Amp & Gent for 48' R/O. BC remains
negative.


Nursing Note 7p-7a

ROS: See carevue for exact data

N: Pt easily arousable. Bizarre comments noted throughout the night, obvious confusion, but easily re-orienting. Oriented x2-3. MAE's, follows commands. Pupils 3 mm brisk/bilat. Speech clear. Pt c/o some pain to RLE, dilaudid .25 mg as tolerated with effect.

CV: SR 60-70's, no ect. BP stable see carevue for documentation. D5 [**12-3**] for maintanence fluids. Palpable DP pulses, unable to assess PT due to splints. Ext's warm, swollen, wnl csm. Brusing to left foot. CSM frequently checked through the night, documented q4 hrs. Pt able to wiggle toes, move legs on bed. Unable to use venodynnes. IV lopressor held [**Month/Day (2) 172**] per parameters.

Resp: LS diminished. Enc to cough and deep breath, reposition as tolerated. Dyspneic with turns. Will attempt to direct pt on I/S today. Pt able to cough up secretions. Sats on 2 liters 95-97%. CPT as tolerated.

Gi: Abd softly distended.Positive BS. Pt taking sips of clears. ? Advance diet today. Bowel regimen and H2 blocker

Gu: Adeq Bun/Crt. U/o borderline all noc. MD [**Doctor Last Name 717**] ok with 25 ccs per hr. Bolus'd earlier in shift for low u/o. Clr yellow.

Skin: Bilat splints. Abrasion to abdomen. Contusion to post rt knee. Blister noted to left foot, intact. Backside wnl.

Endo: Bld sugars 130's

Lytes: Pt will need potassium repletion.

Hem: Hct 25.2 down from 25.7 slow drift.

ID: Tmax 100.1, wbc 7.7 IV cefazolin x1 more dose this a.m.

Soc: Family involved, daughter called [**Name2 (NI) 172**].

Plan: Pan to medicate for pain. Repair of left foot. Pulm toilet/CPT. Advance diet in a.m. Monitor u/o. Lyte repletion. Monitor skin integrity. Hct checks changed to QD per DR. [**Last Name (STitle) 717**]. Cont to monitor.


[**2105-12-26**] 4:04 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 81396**]
 Reason: Please assess CVL Placement
 Admitting Diagnosis: FEVER;PARALYSIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


23 year old woman with RIJ CVL placed in OR


REASON FOR THIS EXAMINATION:


Please assess CVL Placement
 ______________________________________________________________________________


FINAL REPORT


REASON FOR


EXAMINATION:


Evaluation of right internal jugular line placement.

 Portable AP chest radiograph was reviewed with no prior studies available for
 comparison.

 The ET tube tip is 2 cm above the carina.  The right internal jugular line tip
 is at the cavoatrial junction.  The patient is after recent surgery given the
 presence of the cutaneal clips.  The cardiomediastinal silhouette is
 unremarkable and the lungs are clear.

 Note is made of a significantly distended splenic flexure.


npn
s=moaning
o=neuro=pupils equal and reactive.  nods head and occas. answers questions with yes or no.  moves all extremities and follows commands inconsistently.

cv=monitor=st with no ectopy.  occas. bursts of svt to 130's, self-resolved.  bp 140-180's.  [** **] with mso4 and ativan for pain control with good return of bp to 140's.  ivf at kvo.  tpn at 83.3.  see careview for all vital signs, etc.

pulm= sats on 40% face tent dropping to low 90's.  changed from tent to mask at 50% and much improved sats.  breath sounds clear upper bilaterally but decreased at bases bilaterally.  coughs at times--no secretions.

gi=faint hypotonic bowel sounds.  no drg. from ileostomy.  scant to no drg. from jp drains.  sm. amt green drg. from pigtail.  ngt to [** 3085**].  patent for brown gastric contents.  tube feeds via [** **] at 20cc/hr.

gu= foley patent for lg. amts clear yellow urine.

skin=no issues.  dressing changed this a.m. on rounds by team.

endo=no issues.

a=pain control seems to be major issue in bp control.

p=continue to sedate for pain as needed with adjustment of antihypertensives.


Admission Date:  [**2136-1-11**]              Discharge Date:   [**2136-2-17**]

Date of Birth:  [**2075-3-5**]             Sex:   F

Service: MEDICINE

Allergies:
Xanax

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
right lower extremity worsening heel ulcer

Major Surgical or Invasive


Procedure:


[**2136-1-12**]: Debridement of right heel skin and subcutaneous tissue
down to bone.
[**2136-1-14**]: Right excisional debridement, partial calcanectomy
right side.
[**2136-1-23**]: Debridement of skin and subcutaneous tissues right
heel.

[**2136-1-23**]: Debridement of open wounds right side and right
ischium measuring 12 x 12 cm on the right thigh, and 9 x 8 cm on
the right ischium, and placement of vacuum-assisted closure
dressing.


History of Present Illness:
Ms. [**Known lastname 17025**] is a 60 year old woman who presents to the ED
with wet gangrene of her right heel.  She is s/p b/l
femoral-popliteal bypasses and a TMA of her left foot. Her
symptoms began 1 month ago when she noted redness of her
right leg and foot.  She treated this with some form of ointment
after which she noted worsening drainage from her heel prompting
her to be admitted to [**Hospital 1474**] Hospital.  She was started on
Invanz, a PICC line was placed on [**1-3**] and she was transferred
to a rehab facility.  Per the rehab records she initially was
admitted with dry gangrene of the heel which has progressively
worsened.  She was evaluated by wound care nursing and a
[**Month/Day (4) 1106**] surgeon who felt inpatient admission and debridement
would be needed and she was therefore transferred to [**Hospital1 18**] for
further care.  She denies fevers and chills, but does report
significant pain in her right foot.

Past Medical


History:


PMH: Diabetes, Hypertension, Obesity, Smoking, Anemia, CAD, CHF,
GERD, hx of VRE

PSH:
- CABG x2 c/b sternal wound infections requiring multiple
debridements and skin grafting '[**30**]
- ventral hernia repair '[**30**]
- L CFA-AK [**Doctor Last Name **] BPG c/b left groin MRSA infection [**7-3**]
- L TMA [**9-2**]
- s/p ORIF L supracondylar femur fx on [**2133-6-4**] and revision
[**2133-7-4**]
- Angioplasty of L BPG [**12-4**]
- R CFA-AK [**Doctor Last Name **] BPG w/ NRSV c/b groin infection w/ proteus,
pseudomonas requiring debridement [**12-4**]


Social


History:


Former smoker 2ppd x 20 years, quit 25 years ago. Denies alcohol
or IVD use. Lives with sister.


Family


History:


non-contributory

Physical


Exam:


Vital Signs: Temp: 97.4 RR: 20 Pulse: 69 BP: 139/60
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.

Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, abnormal: Obese, large midline
scar from hernia repair.
Extremities: Abnormal: Difficult groin exam given significant
pannus.  B/L venous stasis changes, L TMA well healed.

Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P.
LUE Radial: P.
RLE DP: P. PT: P.
LLE DP: P. PT: D.

DESCRIPTION OF WOUND: Large area of wet gangrene over right heel
with surrounding erythema, unable to express puss.  Does not
probe to bone.


Pertinent Results:
[**2136-2-17**] 09:17AM BLOOD WBC-11.3* RBC-2.84* Hgb-8.0* Hct-24.8*
MCV-87 MCH-28.2 MCHC-32.2 RDW-17.6* Plt Ct-358
[**2136-1-11**] 05:15PM BLOOD Glucose-190* UreaN-34* Creat-1.2* Na-138
K-4.5 Cl-99 HCO3-30 AnGap-14
[**2136-1-23**] 06:00AM BLOOD Glucose-94 UreaN-42* Creat-2.2* Na-138
K-4.0 Cl-105 HCO3-26 AnGap-11
[**2136-1-29**] 04:29AM BLOOD Glucose-115* UreaN-52* Creat-3.7* Na-135
K-3.7 Cl-103 HCO3-25 AnGap-11
[**2136-1-30**] 04:40AM BLOOD Glucose-80 UreaN-53* Creat-4.2* Na-134
K-3.5 Cl-101 HCO3-23 AnGap-14
[**2136-1-30**] 03:30PM BLOOD Glucose-94 UreaN-55* Creat-4.3* Na-136
K-3.8 Cl-102 HCO3-24 AnGap-14
[**2136-1-31**] 03:54AM BLOOD Glucose-80 UreaN-56* Creat-4.4* Na-135
K-3.8 Cl-102 HCO3-25 AnGap-12
[**2136-1-31**] 05:03PM BLOOD Glucose-136* UreaN-55* Creat-4.2* Na-134
K-3.9 Cl-101 HCO3-24 AnGap-13
[**2136-2-1**] 04:10AM BLOOD Glucose-95 UreaN-56* Creat-4.2* Na-136
K-3.6 Cl-101 HCO3-26 AnGap-13
[**2136-2-1**] 05:57PM BLOOD UreaN-55* Creat-4.0* Na-135 K-3.5 Cl-99
HCO3-25 AnGap-15
[**2136-2-2**] 04:06AM BLOOD Glucose-115* UreaN-53* Creat-3.9* Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
[**2136-2-7**] 08:03PM BLOOD UreaN-42* Creat-2.8* Na-131* K-3.9 Cl-94*
[**2136-2-14**] 05:10AM BLOOD Glucose-121* UreaN-46* Creat-2.1* Na-133
K-4.2 Cl-92* HCO3-32 AnGap-13
[**2136-2-15**] 05:37AM BLOOD Glucose-107* UreaN-44* Creat-1.9* Na-135
K-4.1 Cl-94* HCO3-32 AnGap-13
[**2136-2-15**] 02:54PM BLOOD Glucose-155* UreaN-42* Creat-1.9* Na-136
K-4.0 Cl-96 HCO3-31 AnGap-13
[**2136-2-16**] 05:19AM BLOOD Glucose-88 UreaN-43* Creat-1.9* Na-137
K-4.3 Cl-95* HCO3-34* AnGap-12
[**2136-2-16**] 11:15PM BLOOD Glucose-135* UreaN-43* Creat-1.9* Na-135
K-4.2 Cl-95* HCO3-31 AnGap-13
[**2136-2-17**] 09:17AM BLOOD Glucose-134* UreaN-42* Creat-1.8* Na-137
K-4.4 Cl-97 HCO3-31 AnGap-13
[**2136-2-14**] 05:10AM BLOOD Tobra-3.3*
[**2136-2-15**] 05:37AM BLOOD Tobra-1.8*
[**2136-2-17**] 09:17AM BLOOD Tobra-0.8*
.

Foot X rays:


IMPRESSION:


Diffuse soft tissue swelling without definite signs
of soft
tissue gas or foreign body. Probable ulceration along the soft
tissues at the heel without underlying signs of osteomyelitis.
.
[**2136-1-11**] 10:47 pm FOOT CULTURE      Source: R heel.

                            **


FINAL REPORT


[**2136-1-15**]**

   GRAM STAIN (Final [**2136-1-12**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   WOUND CULTURE (Final [**2136-1-15**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      PSEUDOMONAS AERUGINOSA.    HEAVY GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------     2 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S

Time Taken Not Noted     Log-In Date/Time: [**2136-1-12**] 9:27 am
      TISSUE      RIGHT FOOT.

                            **


FINAL REPORT


[**2136-1-29**]**

   GRAM STAIN (Final [**2136-1-12**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   TISSUE (Final [**2136-1-16**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 59049**]
         [**2136-1-12**].

   ANAEROBIC CULTURE (Final [**2136-1-16**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Final [**2136-1-29**]):    NO FUNGUS ISOLATED.

[**2136-1-14**] 2:55 pm TISSUE      RIGHT HEEL.

                            **


FINAL REPORT


[**2136-1-18**]**

   GRAM STAIN (Final [**2136-1-14**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2136-1-18**]):
      STAPH AUREUS COAG +.    1 COLONY ON 1 PLATE.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

   ANAEROBIC CULTURE (Final [**2136-1-18**]):    NO ANAEROBES ISOLATED.


[**2136-1-14**] 3:05 pm TISSUE      RIGHT HEEL MARGIN.

                            **


FINAL REPORT


[**2136-1-20**]**

   GRAM STAIN (Final [**2136-1-14**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   TISSUE (Final [**2136-1-17**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
         ORGANISMS.
         COAG NEG STAPH does NOT require contact precautions,
regardless of
         resistance.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
VANCOMYCIN------------ <=0.5 S

   ANAEROBIC CULTURE (Final [**2136-1-20**]):    NO ANAEROBES ISOLATED.


[**2136-1-17**] 10:44 am STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool.

                            **


FINAL REPORT


[**2136-1-17**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2136-1-17**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

                            **


FINAL REPORT


[**2136-1-25**]**

   GRAM STAIN (Final [**2136-1-23**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2136-1-25**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..

[**2136-1-23**] 1:00 pm TISSUE      RIGHT ISCHIAL WOUND.

                            **


FINAL REPORT


[**2136-2-6**]**

   GRAM STAIN (Final [**2136-1-23**]):
      REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 59050**] @ 630PM [**1-22**].
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.

   TISSUE (Final [**2136-1-27**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    MODERATE
GROWTH.
      PROBABLE ENTEROCOCCUS.    MODERATE GROWTH.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
      YEAST, PRESUMPTIVELY NOT C. ALBICANS.    SPARSE GROWTH.
      [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.    SPARSE
GROWTH.
      PSEUDOMONAS AERUGINOSA.    RARE GROWTH.  SECOND
MORPHOLOGY.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------    32 R       32 R
CEFTAZIDIME-----------  =>64 R     =>64 R
CIPROFLOXACIN---------<=0.25 S   <=0.25 S
GENTAMICIN------------   <=1 S        2 S
MEROPENEM-------------     4 S        2 S
PIPERACILLIN/TAZO----- =>128 R    =>128 R
TOBRAMYCIN------------   <=1 S      <=1 S

   ANAEROBIC CULTURE (Final [**2136-1-27**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Final [**2136-2-6**]):
      [**Female First Name (un) **] ALBICANS.    SENSITIVE TO Fluconazole.
         sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
         This test has not been FDA approved but has been
verified
         following Clinical and Laboratory Standards Institute
guidelines
         by [**Hospital1 69**] Clinical
Microbiology
         Laboratory..  SENSITIVITIES REQUESTED BY DR [**Last Name (STitle) **]
[**2136-1-28**].

[**2136-1-23**] 1:00 pm TISSUE      RIGHT THIGH WOUND TISSUE.

                            **


FINAL REPORT


[**2136-2-6**]**

   GRAM STAIN (Final [**2136-1-23**]):
      REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 59050**] @ 630PM [**2136-1-23**].
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      1+    (<1 per 1000X FIELD):   BUDDING YEAST.

   TISSUE (Final [**2136-2-2**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    MODERATE GROWTH.
         SENSITIVITIES PER DR [**Last Name (STitle) 59051**] [**2136-1-27**].
         COAG NEG STAPH does NOT require contact precautions,
regardless of
         resistance.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      ENTEROCOCCUS SP..    MODERATE GROWTH.
         SENSITIVITIES PER DR [**Last Name (STitle) 59051**] [**2136-1-27**].
         Daptomycin Susceptibility testing requested by K [**Doctor Last Name 3689**]
[**3-/4872**]
         [**2136-1-31**].
         Daptomycin =3MCG/ML Sensitivity testing performed by
Etest.
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    MODERATE
GROWTH.
      [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].    SPARSE GROWTH.
         Further workup requested by DR [**Last Name (STitle) **].FLASH [**2136-1-27**].
         SENSITIVE TO Fluconazole , sensitivity testing
performed by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
         This test has not been FDA approved but has been
verified
         following Clinical and Laboratory Standards Institute
guidelines
         by [**Hospital1 69**] Clinical
Microbiology
         Laboratory..
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 59052**],
         [**2136-1-23**].
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.  SECOND
MORPHOLOGY.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 59052**],
         [**2136-1-23**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |          ENTEROCOCCUS SP.
                             |          |
AMPICILLIN------------             =>32 R
CLINDAMYCIN-----------<=0.25 S
DAPTOMYCIN------------                  S
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------  =>16 R
LEVOFLOXACIN----------     4 R
LINEZOLID-------------                2 S
OXACILLIN-------------   =>4 R
PENICILLIN G----------             =>64 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
VANCOMYCIN------------     2 S     =>32 R

   ANAEROBIC CULTURE (Final [**2136-1-27**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Final [**2136-2-6**]):
      [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].

[**2136-2-6**] 4:36 pm BLOOD CULTURE      Source: Line-Picc.

                            **


FINAL REPORT


[**2136-2-12**]**

   Blood Culture, Routine (Final [**2136-2-12**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days.
         SENSITIVITIES PERFORMED ON REQUEST..
         OF TWO COLONIAL MORPHOLOGIES.

   Aerobic Bottle Gram Stain (Final [**2136-2-7**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5143**] @ 720PM  [**2136-2-7**].
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.

[**2136-2-8**] 12:25 pm SWAB      Source: Deep Right Buttocks.

                            **


FINAL REPORT


[**2136-2-12**]**

   GRAM STAIN (Final [**2136-2-8**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.

   WOUND CULTURE (Final [**2136-2-12**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------  =>64 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------     2 I
GENTAMICIN------------     4 S
MEROPENEM-------------  =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2136-2-12**]):    NO ANAEROBES ISOLATED.
[**2136-2-8**] 12:25 pm SWAB      Source: Right Ischial ulcer .

   GRAM STAIN (Final [**2136-2-8**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   WOUND CULTURE (Preliminary):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      WORK UP REQUESTED PER DR. [**Last Name (STitle) 10000**] [**2136-2-9**] .


Chief Complaint:
   69M with recently diagnosed high grade sarcoma s/p resection presents
   from NH with hypoxic respiratory failure likely from aspiration of GI
   contents in setting of ileus.  Pt now w/ progressive neurologic
   decline/paralysis of Les in setting of expansion of RP mass/sarcoma on
   CT. Continued coordination with palliative care re: home with hospice
   vs inpatient hospice; multidisciplinary meeting yesterday led to
   decision not to escalate care, not to pursue XRT and to endeavor to get
   Mr [**Known lastname **] home with hospice.
   He remains off CPAP overnight per pt preference.
   Allergies:
   Aspirin
   Nausea/Vomiting
   Last dose of Antibiotics:
   Piperacillin/Tazobactam (Zosyn) - [**2104-8-8**] 06:20 PM
   Vancomycin - [**2104-8-9**] 12:35 AM
   Infusions:
   Other ICU medications:
   Morphine Sulfate - [**2104-8-9**] 05:00 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  [**2104-8-9**] 07:47 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.2
C (100.7
   Tcurrent: 37.9
C (100.2
   HR: 96 (87 - 102) bpm
   BP: 127/50(68) {97/48(62) - 127/61(75)} mmHg
   RR: 17 (13 - 21) insp/min
   SpO2: 96%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 71 Inch
             Total In:
                                                                  1,603 mL
                                                                    328 mL
   PO:
                                                                    580 mL
             TF:
   IVF:
                                                                  1,023 mL
                                                                    328 mL
   Blood products:
   Total out:
                                                                  1,385 mL
                                                                  1,050 mL
   Urine:
                                                                  1,385 mL
                                                                  1,050 mL
   NG:
   Stool:


PATIENT/TEST INFORMATION:


Indication:


Chest pain. Left ventricular function. Myocardial infarction. Preoperative assessment.
Height: (in) 55
Weight (lb): 145
BSA (m2): 1.53 m2
BP (mm Hg): 105/60
HR (bpm): 95
Status: Inpatient
Date/Time: [**2175-9-29**] at 10:36
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: Normal LA and RA cavity sizes.

RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.

LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global
systolic function (LVEF >55%). Mild regional LV systolic dysfunction. No
resting LVOT gradient.

LV WALL MOTION: Regional LV wall motion abnormalities include: inferior apex -
hypo;

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: No 2D or Doppler evidence of distal arch coarctation.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.

MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate ([**1-15**]+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.
Indeterminate PA systolic pressure.

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium and right atrium are normal in cavity size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF >55%). There is
mild regional left ventricular systolic dysfunction with very mild hypokinesis
of the distal inferior wall. The remaining segments contract normally (LVEF =
60 %). Right ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate (1+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild to moderate ([**1-15**]+) mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be quantified. There
is no pericardial effusion.


IMPRESSION:


Normal left ventricular cavity cavity size with very mild regional
systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation. Mild aortic
regurgitation. Dilated ascending aorta.

CLINICAL IMPLICATIONS:
Based on [**2171**] AHA endocarditis prophylaxis recommendations, the echo findings
indicate prophylaxis is NOT recommended. Clinical decisions regarding the need
for prophylaxis should be based on clinical and echocardiographic data.


NPN 7pm-7am


RESP: Infant is in RA. RR 50-70's with sats > 92%. LS clear
and equal with mild IC/SC rets. No spells at this time in
shift. On Caff. A: Stable in RA. Infant less tachypneic this
shift. P: will cont to monitor resp status.

FEN: Current weight 1290gms up 15gms. TF 150cc/kg/day of IVF
and Ent feeds. IVF are at 90cc/kg/day of PN D12 and IL
running through DLUVC. Ent feeds are at 60cc/kg/day of BM/SC
20cals = 14cc's q4hrs gavaged over 20mins. Increasing
10cc/kg/[**Hospital1 **]. Abd soft, girth stable, +bsl, no loops. No
spits and min asp. Voiding and no stool. Planned for lytes
with next care. A: Tol increase in feeds well. P: will cont
to monitor weight and exam.

G/D: Infant is nested on sheepskin with boundries in servo
isolette. TEmp stable. Alert and active with cares. Sucks on
pacifier. Comforted on stomach. Sleeps well between cares.
A: Growing premie. P: Will cont to support dev needs.

[**Hospital1 **]: No contact from [**Name2 (NI) **] at this time in shift.

BILI: Infant remains under single phototherapy with eye
covered. A: Jaundice. Feeding well. P: will check bili level
this am and cont to monitor.


70-year-old woman in her usoh until 3 days prior to admission with c/o
   generalized myalgias, abdominal/shoulder pain, and sob. She was sent to
   [**Hospital1 5**] ed by her pcp who found the pt to have a room air saturation of
   80%. In the ed, the pt
s respiratory status continued to deteriorate
   and she was eventually intubated fiberoptically. She was transferred to
   the micu for further care, which has included the need for multiple
   pressor support, a paralytic, and nitrous oxide. She had a pea arrest
   over the weekend. The FDA released permavir on [**2151-10-31**] to empirically
   treat for h1n1 since the pt cannot absorb po meds.
   [**11-1**]
Patient with PEA arrest (D/T hypoxia with ST rhythem), Due to
   ventilator tubing was disconnected.  She was bagged and given epi with
   return of BP and pulse.  Was given a recruitment maneuver after which
   she suddenly dropped tidal volumes and briefly arrested again.  Thick
   purulent suctions removed from ETT c/w plug.  SBP dropped to 40
s and
   did not respond to neo. Another [**12-11**] amp epi.  Each epi bolus was
   accompanied by severe HTN to 250/180 range.  Pt was paralyzed again due
   to being desynchronized on the vent.
   [**11-3**]
 Pt arrested again (4^th time). Placed back on paralytics. Pt CV
   X 2 s/p epi due to HR of 200-300 and hypertension.
   Events:
          Head, face, chest, abd, and pelvic CT done, results pending.
          Lasix x1 to cont diuresing w/ FB goal net neg 1L
          Pt afebrile, Tylenol changed from prn to q6hr sched.
   Fever, unknown origin (FUO, Hyperthermia, Pyrexia)
   Assessment:
   Pt temp this am 99.6, fan on in room.
   Action:
   Tylenol order changed to q6hr sched. Dose, given a/o Blood and urine cx
   sent a/o unable to obtain enough sputum via ETT for spec.
   Response:
   Temp remained flat this shift currently 99.0
   Plan:
   Continue to monitor temp, Tylenol abx a/o, f/u cx results.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 76**])
   Assessment:
   Pt remains orally intubated and treated for Rt sided pna
 ARDS and for
   H1N1. Vent settings unchanged. Rec
d on Nimbex at max dose
   0.3mcg/kg/min w/ TOF 0-1/4 LS rhonchi on the right clear on the left w/
   dim bases. ABG. Remains sedated on fent and versed w/ gtt rates
   unchanged. 02 sat 95-100%
   Action:
   Nimbex gtt decreased to 0.28mcg/kg/min, vent settings unchanged,
   head/torso CT done w/ OGT contrast.
   Response:
   ABG
s remain stable, TOF after decreasing Nimbex 3-4/4, Nimbex changed
   to 0.29mcg/kg/min. chest CT showed Bilat pleural effusion R>L,
   evaluated for thoracentesis bby team , but not done r/t poor
   visualization via US. PM ABG 7.48/39/74
   Plan:
   Plan to continue paralytics for now. Continue to wean vent settings as
   tolerated by pt. Follow up cultures.
   Hypertension, benign
   Assessment:
   Pt found at 8am to have a SBP of 160-170
s with MAP of 100-118. HR ST
   at 104-106 with occ PVCs. NIBP = A-line.
   Action:
   No treatment for now for hypertension [**Name8 (MD) 77**] MD, unless MAP is > 120. BP
   monitored very closely via a-line. Wave form sharp.
   Response:
   No new changes to BP.
   Plan:
   ? need to start BP medications.
   Diabetes Mellitus (DM), Type I
   Assessment:
   Pt found at 8am to be on insulin gtt at 6 units/hr. FSBS in the mid->
   high 100
   Action:
   Pt started on d5w at 125ml/hr x 1L to correct Hypernatremia,
   subsequently Insulin gtt increased as noted per protocol.
   Response:
   FSBS increased intop the 200
s following start of d5w, insulin gtt
   titrated to 18units/hr.
   Plan:
   Follow FSBS very closely.


Respiratory Care:
Pt put on mask  ventilation during the night. Pt then put on Hi-flow 95% with 2l/m NC for five hours before tiring. Pt then put back on mask ventilation for two hours and then will return to HI-Flow O2 for four hours. Pt tolerates this rountine and does not seeem to tire or have increased WOB. Albuterol/Atrovent treatments given as needed. Will monitor as needed.


Sedation off for neuro exam, opens eyes to sternal rub, restless thrashing around bed, purposeful movement of right arm and leg, posturing of left arm, and no movement of left leg, [** 532**], Prop placed back on,
CV-VSS MP SR no VEA CSM WNL
Resp-Fio2 weaned to 40% and PEEP weaned to 8, Sao2 98, will recheck ABG, LS Coarse upper lobes dim at bases, sx for scant thick tan
GI-TF held NS at 70cc/hr, awaiting IR placement of feeding tube, +BS
GU-foley to cd u/o adequate
Skin-coccyx red skin barrier cream to area

Plan-vent wean as tolerates, PEG placement, maintain pts comdort, cont ABX, neuro cks


[**2193-1-3**] 1:20 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 108997**]
 Reason: arrythmia
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


70 year old man with s/p quinton placementincrease wbc and  arrthymia


REASON FOR THIS EXAMINATION:


arrythmia
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


S/P Quentin placement.  Check position.  There is also increasing
 white count and arrhythmia.

 Single view of the chest is compared to a prior study dated [**2192-12-6**].

 There is an appropriately positioned right-sided Quentin catheter.  There is a
 left-sided Swan-Ganz catheter, which is coiled within the right ventricle, and
 the distal tip is located too distally in the pulmonary vasculature; the
 catheter should be withdrawn at least 10 cm. There is ectasia of the aorta.
 The heart is difficult to adequately assess. There is increasing linear
 opacities at both bases, suggesting subsegmental atelectasis.  The upper lung
 zones are clear. There is no pneumothorax.

 There are sternal wires and clips overlying the cardiac silhouette, consistent
 with prior CABG.  There are clips in the right upper quadrant, suggesting a
 prior cholecystectomy.


IMPRESSION:


Appropriately positioned right Quentin catheter.  There is a malpositioned
 Swan-Ganz catheter, as detailed above.  The findings were discussed with the
 house staff.

 There is increasing subsegmental atelectasis at the bases.


[**2188-11-27**] 7:46 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 26**] # [**Clip Number (Radiology) 2936**]
 Reason: Eval for interval change after pigtail removal.
 Admitting Diagnosis: ABDOMINAL PAIN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


67F w/ gallstone pancreatitis c/b aspiration, PEA arrest, intubation, extubated
  today. Left pigtail removed today.


REASON FOR THIS EXAMINATION:


Eval for interval change after pigtail removal.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Aspiration and arrest with intubation with pigtail catheter recently
 removed, to assess for change.


FINDINGS:


In comparison with the earlier study of this date, the endotracheal
 and nasogastric tubes have been removed.  There is extensive opacification in
 the right hemithorax consistent with a large pleural effusion.  On the left,
 there is retrocardiac atelectasis with substantially smaller pleural effusion.
 No definite pulmonary vascular congestion.


[**2136-7-25**] 8:19 PM
 MR [**Name13 (STitle) 3106**] W &W/O CONTRAST                                      Clip # [**Clip Number (Radiology) 24309**]
 Reason: Assess for abscess in rest of spinal cord
 Admitting Diagnosis: SEPSIS
  Contrast: MAGNEVIST Amt: 20
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


64 year old woman with abscess in lumbar spine


REASON FOR THIS EXAMINATION:


Assess for abscess in rest of spinal cord
 ______________________________________________________________________________


FINAL REPORT


MR SCAN OF THE THORACIC SPINE WITH CONTRAST ENHANCEMENT


HISTORY:


Assess for status of known large epidural abscess.


TECHNIQUE:


Multiplanar T1- and T2-weighted gadolinium enhanced thoracic spine
 imaging was obtained.

 COMPARISON STUDY:  MR scan from [**2136-7-22**].


FINDINGS:


The large primarily ventrally situated epidural abscess is again
 seen.  However, there is more internal T1 hypointensity, particularly at the
 thoracolumbar junction.  This finding likely reflects that the contents of the
 infection include pus, as opposed to a simple phlegmon.  The midthoracic high
 T2 signal within several vertebral bodies as well as their intervening disc
 spaces does suggest the presence of discitis and osteomyelitis.  The right
 lower lung pleural-based hypointense region surrounded by gross contrast
 enhancement raises the question of probable multiple abscesses in this locale.
 These findings were present on the prior studies, including the prior CT scan
 of the abdomen and pelvis from [**2136-7-17**].

 CONCLUSION:  The present study suggests that there is a component of pus
 within the large epidural abscess/phlegmon.

 COMMENT:  Due to very limited image quality, precise assessment of cord signal
 is difficult to achieve.  Clearly, this patient is at significant risk for
 septic thrombophlebitis leading to cord infarction.

 All of these findings, as well as those noted on other studies performed the
 same day were discussed with Dr. [**First Name8 (NamePattern2) 946**] [**Last Name (NamePattern1) 13**] and her infectious disease
 colleagues today ([**2136-7-26**]) at 9AM.


[**2163-8-22**] 6:36 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 53685**]
 Reason: please evaluate OG tube placement
 Admitting Diagnosis: MULTI LOBE PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


52 year old man with respiratory failure and multi-lobar pna


REASON FOR THIS EXAMINATION:


please evaluate OG tube placement
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Evaluate OG tube placement.

 PORTABLE AP CHEST:  Comparison is made to study from [**2163-8-21**].  OG tube is
 again visualized and remains relatively unchanged in position from the
 previous studies.  The tip extends beyond the inferior margin of the imaged
 field and not visualized.  ET tube and right sided central venous line are
 again seen and unchanged in position.  Right sided pleural effusion, extending
 into the minor fissure is again seen.  No left pleural effusion is seen.  The
 heart size and mediastinal contours are unchanged.  No new infiltrate is seen.


IMPRESSION:


OG tube appears unchanged in position from previous exam.  Right
 pleural effusion is again seen.  Exam is otherwise relatively unchanged.


Sinus rhythm.  Right bundle-branch block.  Inferior and lateral precordial
leads.  ST-T wave changes are primary and non-specific.  Clinical correlation
is suggested.  Since the previous tracing of [**2196-12-27**] ventricular ectopy is
absent and lateral precordial lead ST-T wave changes appear slightly more
prominent, but there may be no significant change.


[**2153-12-21**] 5:44 PM
 CHEST (PRE-OP PA & LAT)                                         Clip # [**Clip Number (Radiology) 59675**]
 Reason: CONGESTIVE HEART FAILURE;CHEST PAIN;+ETT\CATH
 Admitting Diagnosis: CONGESTIVE HEART FAILURE;CHEST PAIN;+ETT\CATH
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


75 year old man with multivessel CAD, pre op for CABGPatient on bedrest until
  5pm. thanks


REASON FOR THIS EXAMINATION:


r/o pulmonary process
 ______________________________________________________________________________


FINAL REPORT


EXAM ORDER:  Chest.


HISTORY:


Preop for CABG.

 Chest PA and lateral views are interpreted without prior films available for
 comparison.  The heart size is upper normal limits.  There is calcified
 atheromatous plaque in the aortic arch.  The lungs are clear.  There is
 blunting of the left costophrenic sulcus.


IMPRESSION:


No evidence of acute pulmonary disease.


Chief Complaint:
   24 Hour Events:
 TRANSTHORACIC ECHO - At [**2188-3-14**] 08:47 AM
 ULTRASOUND - At [**2188-3-14**] 10:03 AM
   renal
 EKG - At [**2188-3-14**] 12:28 PM
   regular and R sided leads done
 PICC LINE - START [**2188-3-14**] 02:56 PM
   - Patient's cardiac enzymes increased from CK 500 to 800s, trop up to
   1.88, prelim TTE showing multivessel disease, LV systolic dysfunction
   so ASA 325 and simvastatin 80 given and cards consult called
   - Patient given 2 units pRBCs throughout day with goal to keep Hct>30,
   given 20IV lasix w 2nd unit
   - PICC placed for access
   - GI recs: Will wait until more clinically stable for EGD/[**Last Name (un) **]. EGD as
   found to have ETOH history
   - Cards recs: likely demand ischemia rather than plaque rupture. Agree
   with ASA, high dose statin, lasix prn. Chads2 = 3, may benefit from
   coumadin after acute issues, later add BB, ACEi.
   - Lactate decreased 2.1 to 1.2
   - Had mild hematuria overnight
   History obtained from Patient
   Allergies:
   History obtained from Patient
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Pantoprazole (Protonix) - [**2188-3-14**] 08:02 PM
   Furosemide (Lasix) - [**2188-3-14**] 10:48 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  [**2188-3-15**] 06:32 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**89**] AM
   Tmax: 36.4
C (97.5
   Tcurrent: 35.9
C (96.6
   HR: 80 (68 - 88) bpm
   BP: 134/63(81) {98/42(55) - 151/89(106)} mmHg
   RR: 17 (14 - 26) insp/min
   SpO2: 97%
   Heart rhythm: AF (Atrial Fibrillation)
   Height: 71 Inch
    Mixed Venous O2% Sat: 88 - 88
   Total In:
                                                                  5,239 mL
                                                                    208 mL
   PO:
                                                                    270 mL
                                                                    120 mL
   TF:
   IVF:
                                                                  4,170 mL
   Blood products:
                                                                    799 mL
                                                                     88 mL
   Total out:
                                                                    507 mL
                                                                  1,070 mL
   Urine:
                                                                    507 mL
                                                                  1,070 mL
   NG:
   Stool:


Respiratory Care
Pt remains intubated and on vent support. Vent changes were PS from 18 to 12. Volumes remained good and RR increased to mid 20's. Pt was placed onto a SBT per SICU team @ rounds. Pt lasted 20 minutes on 8/0. HR was then >130 then placed back onto previous settings. Another SBT in morning. Lung sounds were course with an exp wheeze in the RUL. Pt was suctioned for small/moderate amounts of [** **] white secretions. Pt received MDI's with good effect. No ABG were drawn during shift. Care plan is to continue to wean PS as [** **] and to continue SBT after passing RSBI in mornings. Will continue to follow pt.


Nursing Admission Note


     34 week baby girl [**Name2 (NI) **] to a 37 yo G5 P1-2 mother.  [**Name (NI) 25**]
above note written by MD.
     D/T FIO2 requirement and retractions placed NP CPAP 6cm
FIO2 on CPAP 32-40%.  CXR obtained and looked at by team.
RR mostly 60-70's.  D/T tachypnea and FIO2 requirement CBG
obtained 7.24/38/69/17/-10 and 18cc NS bolus given over 10
min.  Breath sounds coarse, Sxn ETT for small white
secretions and orally for mod amts of old blood tinged
secretions.  Will continue to monitor resp status closley,
   Started infant on D10w at 60cc/kg/d.  D-sticks 96 and
107.  Void X1 2cc, no stools.  Abdomen soft/flat active
bowel sounds.
Infant placed on servo warmer.  Temp stable.  Infant is
alert and active with irritability with cares.
  CBC and blood cultures done.  Amp and Gent given as
ordered.  Will monitor for s/s sepsis.
**Plan to check 24 hr lytes and bili tomorrow.


[**2178-3-25**] 10:31 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 23325**]
 Reason: infiltrates, lines
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


[**Age over 90 **] year old woman with sob,tachycardia and prior desaturation to 80's,
  persistent tachy and now increased RR, and aggitation


REASON FOR THIS EXAMINATION:


infiltrates, lines
 ______________________________________________________________________________


FINAL REPORT


PORTABLE UPRIGHT CHEST 10:31 A.M.


INDICATION:


Shortness of breath.  Persistent tachycardia and agitation.


FINDINGS:


The study is extremely limited due to patient motion (probably
 related to agitation).  Compared with 5/8, the heart and mediastinum are
 unremarkable and unchanged.  The right lower lung field cannot be evaluated
 due to respiratory motion.  No obvious segmental consolidating infiltrates are
 seen in the remainder of the lung fields.  No florid pulmonary edema.


85 year old man with a hx of laryngeal CA s/p laryngectomy w/permanent
   tracheostomy p/w decreased responsiveness and hypotension.  Pt. had
   been suffering through a cough and likely COPD exacerbation with
   pneumonia based on pervious pulmonary records.  According to family,
   pt. was feeling progressively short of breath the day of admission and
   was suctioning himself when suddenly became far less responsive,
   slumped over, only responding with nods to daughter.  Daughter called
   911, was found to be flaccid by EMS with cold extremities.  Intubated
   through his stoma in driveway with resultant return of color and NSR on
   EKG with inferior ST changes.
   .
   .H/O hypertension, benign
   Assessment:
   ABP 165-186/54-72, MAPs 88-118.   HR 53-68, NSR/SB w/ occasional to
   frequent PVC
s.  Had several runs of wide complex SVT during which SBP
   would decrease to low 100
s- Resident notified.  K 3.4. Phos 1.7.
   Action:
   Given standing dose of atenolol. Given 10mg IV hydralazine x2 separate
   doses.  Given 60mEq potassium PO and 15mmol of K phos. EKG done.
   Response:
   Denied SOB, CP, dizziness, or discomfort during wide complex SVT.
   Plan:
   Monitor BP/HR.  Monitor electrolytes.
   Altered mental status (not Delirium)
   Assessment:
   Alert, ox4 (person, place, time, president). Appeared slightly confused
   at times.  Had difficulty remembering RN.  Able to be reoriented
   easily.
   Action:
   Reoriented frequently. Attempted to help patient sleep.  Room quiet,
   trazadone 12.5mg PO given, positioned for comfort.
   Response:
   Unable to sleep most of night.  No change in mental status.
   Plan:
   Monitor mental status. Reorient frequently.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 76**])
   Assessment:
   Remains on trach mask @ 40%.  LS- insp wheezes.  O2 sats 98-100%.
   Action:
   Suctioned for scant amt of thick, yellow secretions. Continued
   antibiotics.  Continued inhalers and nebs.  Frequent position changes.
   Response:
   O2 sats remained 98-100%.  Denied resp difficulty.
   Plan:
   Suction as needed. Continue antibiotics, inhalers.


[**2120-10-24**] 12:55 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 7003**]
 Reason: please check placement of left basilic PICC line  please pag
 Admitting Diagnosis: RETROPERITONEAL HEMORRHAGE;TELEMETRY
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


23 year old woman with retroperitoneal hemorrhage,


REASON FOR THIS EXAMINATION:


please check placement of left basilic PICC line  please page IV nurse [**First Name (Titles) **] [**Last Name (Titles) 2740**]
  [**Location (un) 464**]  thanks #[**9-/2559**]
 ______________________________________________________________________________


FINAL REPORT


CHEST AP PORTABLE SINGLE VIEW.


INDICATION:


Retroperitoneal hemorrhage, placement of left-sided PICC line,
 STAT report requested.


FINDINGS:


AP single view of the chest.  Multiple external wires are overlying
 the upper chest.  Indwelling tube consists of an NG tube terminating in the
 fundus of the stomach.  A left-sided PICC line can be identified and is seen
 to deviate in cranial direction in the neck, apparently entering the left
 jugular vein in retrograde fashion.  There is no evidence of any hematoma or
 pneumothorax.


IMPRESSION:


Inappropriate termination of left-sided PICC line in internal
 jugular vein.  Reposition required.  Telephone report delivered as requested.


ADDENDUM TO ABOVE NOTE
D: UO HAS BEEN <30CC'S/HR SINCE 1100. DR. [**First Name (STitle) **] CALLED AND ADDITIONAL 500 CC NS BOLUS GIVEN AND WILL FOLLOW UO CLOSELY


Respiratory CAre Note
Vent settings weaned to 20/6 R 20 FIO2 21%.  CBG attempted x2 clotted x2.  ABG drawn(7.52/29/67/24/1).  Vent setting weaned to 17/5 RR 15 FIO2 21%.  B.S. clear with good air entry.  Pt extubated.  B.S. clear and equal.  Pt on room air SAO2 95-98%.


Admission Date:  [**2131-6-5**]       Discharge Date:  [**2131-9-12**]

Date of Birth:   [**2093-10-20**]       Sex:  F

Service:  MICU-[**Location (un) **]

                        ADDENDUM

Please note that this discharge summary is an
addendum/continuation of the discharge summary that was done
by Dr. [**First Name (STitle) **] .................. on [**2131-8-27**].

HISTORY OF PRESENT ILLNESS:  The patient is a 37-year-old
white female with a long history of pulmonary issues who is
well known to the [**Hospital6 256**] and i
a patient of Dr. [**Last Name (STitle) 108610**] who was admitted on [**6-5**] for
weaning off her ventilator.  Her ventilator on admission was
CPAP with an FIO2 of 40%, PEEP of 5, and a pressure support
of 30.  She was transferred from the [**Hospital1 **]/[**Hospital1 5042**] Facility
because two weaning trials were attempted which were
unsuccessful.  Hence, it was decided that a weaning would be
carried out in the Medical Intensive Care Unit under the
supervision of her attending Dr. [**Last Name (STitle) 108610**].

PAST MEDICAL


HISTORY:


Please see Dr. [**First Name (STitle) **]
................... initial part of the discharge summary
from [**2131-8-27**].

MEDICATIONS:  Please see Dr. [**First Name (STitle) **] .................
discharge summary from [**2131-8-27**].

ALLERGIES:  SULFA, OXACILLIN, VERAPAMIL.

SOCIAL


HISTORY:


She smoked tobacco for five years while in
college.  She currently resides at the Kindres/[**Hospital1 5042**]
Facility.

HOSPITAL COURSE:  Please see Dr. [**First Name (STitle) **] ..................
discharge summary from [**2131-8-27**], as it describes her
hospital course from the day of admission on [**2131-6-5**],
through [**2131-8-27**].  The remainder of the hospital
course is as follows:

1.  Pulmonary:  The patient has a long history of severe lung
disease.  She has a history of Hodgkin's disease and is
status post CHOP and radiation therapy complicated by
histoplasmosis, adult respiratory distress syndrome, and she
is status post left pneumonectomy for Aspergillus.  She was
recently admitted in the spring for pneumonia.  She had been
on pressure support of 30 with a PEEP of 5 and an FIO2 of 40%
on her admission.  Two attempts were made at the
[**Hospital1 **]/[**Hospital1 5042**] Facility to wean her which were both
unsuccessful.

Her baseline PACO2 is in the 80s, and a renal compensation
brings her bicarbonate in the range of 40-50.  She has
tolerated this well and was able to wean from her vent.  She
was kept on a ................... while she received her
pressure support via tracheostomy at night.  She had a
tracheostomy revision on [**2131-7-2**], and was found to have
a posterior tracheal ulcer which was a very early TE fistula.
She had a temporary tracheostomy which was changed to
permanent on [**2131-7-12**].  A bronchoscopy after that showed
that the ulcer had healed.

The patient is currently using a TP with an FIO2 of 50%
during the day time, and at night she uses a BIPAP with an
EPAP of 6 and an IPAP of 12.  The plan is to send her back to
her rehabilitation center where she will remain on her The
patient during the day with blow-by oxygen and will remain on
the BIPAP at night on her home ventilator.

2.  Cardiac:  The patient has a history of biventricular
congestive heart failure and cardiomyopathy and is known to
have an ejection fraction close to 20%.  Her left-sided heart
failure is thought to be secondary to tachycardia inducing
cardiomyopathy, and her right heart failure is thought to be
secondary to cor pulmonale.  Her resting pulse ranges
anywhere between 100-120s and is sinus tachycardia, and based
on previous experience, it has shown that any decrease or
increase from this resting heart rate, can send her into
respiratory distress and cause decompensation.  She is also
very volume sensitive, and given that she has biventricular
heart failure, our goal is to keep her weight between 150-120
lbs.  In addition, she is on a regimen of Lasix, Metolazone,
and Aldactone to help control her volume status.

She remains at her baseline goal weight between 150-120 lbs
on this diuresis regimen, and she does not appear to have any
respiratory distress.  The patient is also on Digoxin 0.125
mg every other day and 0.25 mg every other day.  She does
have her Digoxin level checked and should be checked on a
regular basis.

Fluids, electrolytes, and nutrition:  The patient is known to
have a volatile/fluctuating potassium level.  She has a
history of constipation and sometimes develops hyperkalemia
from her inability to excrete her potassium to her GI tract.
In addition, with her large diuresis, she also is known to
drop her potassium level significantly in the range of
2.4-2.5.  To help maintain her potassium at a reasonable
level since she is on Digoxin, she is taking 40 mEq Potassium
Chloride t.i.d., and her potassium level has remained
relatively stable in that we had been checking it twice a
day, and it ranges from 3.1 to 4.0 with this current regimen
in addition to the Lasix, Metolazone, and Aldactone she is
taking.

Her nutrition is delivered to her via her G-tube with a
.................. tube feeds.  The patient also has a
baseline metabolic alkalosis as mentioned early on with
bicarbs of 40-50 to compensate for her severely impaired and
decreased ventilation.  She has a significant amount of large
dead space and a VD/VT ratio of 0.8.  She is tolerating this
metabolic alkalosis well.

Gastrointestinal:  As mentioned, the patient has a history of
constipation, especially when she uses narcotic analgesics.
She had been on Percocet for pain experienced from her
tracheostomy site.  She has had some bowel movements since
Dr. ................. discharge summary of [**8-27**], and
her potassium levels have been relatively stable in the range
of 3.0-4.0.  In addition, she is getting Colace 100 mg p.o.
b.i.d., and she is getting Senna tabs and Simethicone.  We
are being very aggressive with her bowel regimen to help
maintain and regulate bowel movements.

Infectious disease:  Given the patient's significant
pulmonary history, she was taking inhaled Tobramycin for
pseudomonas prophylaxis.  She was taking this for 28 days and
then tried off for 21 days in which it was found that her
white blood count was increasing, and the Tobramycin was
restarted.

She does have a history of chronic leukocytosis from [**12-7**],
but no specific signs of infection from her baseline was
noted.  On [**9-6**], she was found to have 15 bands on
her CBC, and she was found to have a positive urinalysis, and
she was started on Levaquin 500 mg p.o. q.d.  In addition on
[**9-6**], she grew coag-negative staph from her PICC line
and was started on Vancomycin because it was sensitive to
that.  On [**9-9**], her urine culture came back negative,
and so the Levaquin was discontinued, but she continued to
receive Vancomycin 1 g q.12 hours for a total of seven days;
on the day of discharge, it will be day #5 of 7.

Psychiatry:  The patient has a history of anxiety attacks
with complicated respiratory failure.  It was thought that
the anxiety was a large component of this failure.  She was
relying on multiple pain medications which had been
discontinued due to her constipation and other problems.  She
seems to be doing well on a regimen of Amitriptyline 75 mg
q.h.s., Zyprexa 5 mg q.h.s., and she occasionally gets Ativan
p.r.n.

Tubes, lines, and drains:  A central line was placed due to
the PICC line infection; however, since she is a very
difficult stick and she need to get her blood checked on a
regular basis, a right PICC line is going to be placed by
Interventional Radiology, and the subclavian is going to be
removed prior to her discharge.  She also has a tracheostomy
and G-tube, and all of these sites are clean, dry, and
intact.

Prophylaxis:  The patient is able to get out of bed with
physical therapy and Occupational Therapy.  She is also
getting a PPI per her G-tube.

DISCHARGE STATUS:  The patient is stable.

DISPOSITION:  The patient is being discharged to either
[**Hospital3 4419**] facility or the [**Hospital1 **]/[**Hospital1 5042**]
Facility depending on bed availability.






                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3795**]

Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36

D:  [**2131-9-11**]  18:55
T:  [**2131-9-11**]  19:06
JOB#:  [**Job Number 108611**]


Underlying atrial rhythm is difficult to discern but is likely organized and
not atrial fibrillation. The ventricular rhythm is via ventricular pacemaker at
a rate of 96. Non-specific repolarization changes. Compared to the previous
tracing of [**2102-5-15**] probably no significant change.


Respiratory care:
Patient remians intubated and mechanically vented. Vent checked and alarms functioning. Current settings: PS 18 Peep 10 Fio2 70%. SPontaneous tidal volumes dropped to 500cc at change of shift. Ps increased to 18 from 15 because of the drop in Vt. Breathsounds are decreased and coarse. Patient suction for copious [**Location (un) 206**] fluid. Please see respiratory section of carevue for further data.
Plan: Continue mechanical ventilation. Wean per protocol.


Nursing Progress Note
  Please see carevue for details of care. Eyes open spontaneously at times but drifts to sleep quickly.  Nods yes/no appropriately, attempts to mouth words around ETT.  Fentanyl gtt at 25mcg, Versed gtt at 1mg/hr.  Alert when awake, responds to family visit, follows commands, MAEW.
  Neck less swollen, skin not as taut as last noc, some tenderness noted to touch.
  B/P remains labile this not but has not required intervention  for B/P support.  Maint B/P 90-110 range w/brief drops to 80's, ? A-line positional.  Cuff B/P correlates to cuff pressure except when ABP      less than 85, NBP remains >85. CVP 4-6. HR 80's consisitently w/no ectopy noted tonight. Foley patent clear yellow urine 80 or >/hr. Tmax 97.9.
  OGT patent Tf infusing well w/minimal residual noted, current TF infusing at 30cc/hr. TLC patent, meds infusing well.
  Remains on vent support AC 700x14x40%+PEEP5 w/O2 sats 98-100%.  Suctions for small amts white secretions.  BS remain clear, dim in bases.
  Family in this pm to support/encourage patient.  Spoke w/attending regarding prognosis and disease process.
  PLAN: Cont to monitor Hemodynamic status and saupport B/P as needed, increase TF as tol to goal, wean vent as able, droplet precautions until cleared  by ID.


Admission Date:  [**2205-8-24**]              Discharge Date:   [**2205-8-27**]

Date of Birth:  [**2128-9-19**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Acute STEMI

Major Surgical or Invasive


Procedure:


Cardiac catetherization

History of Present Illness:
76M with CAD s/p LAD cypher [**3-10**] p/w chest pain. He was in his
USOH free of anginal symptoms until today at roughly 10am when
he developed the acute onset of substernal chest pain radiating
to the L shoulder after vacuuming in his house. He states that
he became diaphoretic noting perspiration on his forehead and
mildly dyspneic and lightheaded, no palpitations. He took a NTG
SL without any change in his sx (he has never before needed a
NTG). His wife called for an ambulance and he arrived to the ED
within 1 hour of the onset of symptoms. Initial vitals in the
ED: t 96.6 p58 111/86 18 98RA. He was found to have ST
elevations V1-4 on the ECG, was started on heparin, integrilin,
given asa, plavix 600mg PO x1. He was sent to the cath lab where
he was found to have a TO LAD within the stent and unable to be
crossed, LCx was TO mid-vessel and RCA had no signifant disease.
POBA was used to treat diag and first septal. The pt tolerated
the cath without complications and was admitted to the CCU
service for monitoring overnight in the setting of STEMI.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for CP, dyspnea, and SOB as
per HPI. No orthopnea, ankle edema, palpitations, syncope or
presyncope.


Past Medical


History:


CAD s/p LAD cypher [**3-10**]
hypertension,
hypotriglyceridemia,
back surgery [**09**] years ago,
arthroscopic surgery on the right knee in [**2197**],
sigmoid polyps and
UGIB [**2-8**] nsaids in [**2198**]
b/l hip replacement


Social


History:


The patient is married, lives with his wife and works in sales
and marketing. He quit smoking 30 years ago and smoked one half
pack per day times 25 years. Occasional Etoh, no illicits. Walks
without need of cane or walker.

Family


History:


Mother died at 83 of CHF and diabetes
Father died at 67 of MI
Brother died of MI in 50s


Physical


Exam:


VS: T 97.8, BP 135/38, HR 61, RR 15, 98O2 % on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: Basilar crackles. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. R groin small hematoma, No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP


Pertinent Results:
[**2205-8-24**] 05:56PM   GLUCOSE-120* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-3.1* CHLORIDE-96 TOTAL CO2-30 ANION GAP-13
[**2205-8-24**] 05:56PM   CK(CPK)-327*
[**2205-8-24**] 05:56PM   CK-MB-54* MB INDX-16.5* cTropnT-0.24*
[**2205-8-24**] 05:56PM   CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.3
CHOLEST-109
[**2205-8-24**] 05:56PM   TRIGLYCER-164* HDL CHOL-35 CHOL/HDL-3.1
LDL(CALC)-41
[**2205-8-24**] 05:56PM   WBC-9.8# RBC-4.11* HGB-13.6* HCT-36.7* MCV-89
MCH-33.1* MCHC-37.0* RDW-14.0
[**2205-8-24**] 05:56PM   PLT COUNT-215
[**2205-8-24**] 05:56PM   PT-11.8 PTT-29.1 INR(PT)-1.0
[**2205-8-24**] 11:45AM   GLUCOSE-109* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-32 ANION GAP-10
[**2205-8-24**] 11:45AM   estGFR-Using this
[**2205-8-24**] 11:45AM   cTropnT-<0.01
[**2205-8-24**] 11:45AM   CK-MB-3
[**2205-8-24**] 11:45AM   WBC-5.1 RBC-4.14* HGB-13.0* HCT-37.0* MCV-90
MCH-31.5 MCHC-35.2* RDW-14.0
[**2205-8-24**] 11:45AM   NEUTS-65.1 LYMPHS-25.5 MONOS-6.7 EOS-2.2
BASOS-0.5
[**2205-8-24**] 11:45AM   PLT COUNT-210
[**2205-8-24**] 11:45AM   PT-11.8 PTT-29.0 INR(PT)-1.0

[**8-24**]  CARDIAC CATH

Brief Hospital Course:
76 yo male with CAD (s/p cypher stent LAD [**2202**]), HTN,
hypercholesterolemia presents with substernal chest pain while
vacuuming.
.
Hospital course presented by problem.
.
#NSTEMI:
Patient initially presented to the ED w/ STEMI.  He was given
ASA, plavix, heparin gtts, integrillin, and morphine.  Patient
urgently underwent cardiac catheterization. An in-stent
thrombosis in the LAD was found but unable to be crossed.  The
diagonal and first septal arteries were opened with angioplasty
but not stented.  Afterwards, the patient remained chest pain
free and hemodynamically stable.  Toprol Xl was titrated up and
he was put on his home dose [**Last Name (un) **] (valsartan) since he gets a
cough to ACE-I.  An echocardiogram showed anterior LV
dysfunction and he was started on anticoagulation for this,
initially w/ heparin and coumadin and then bridged to a
therapeutic INR w/ lovenox 80 mg [**Hospital1 **].  His peak CK was 860.  He
will see his Cardiologist Dr. [**Last Name (STitle) **] tomorrow in [**Location (un) 620**].  He
will take Toprol, valsartan, atorvastatin, aspirin, and plavix.
He was also evaluated by cardiothoracic surgery given his three
vessel disease; he will call to schedule an appointment with
them for a planned CABG in early [**Month (only) **].
.
#PUMP
Systolic dysfunction, EF ~45% as above.  He remained
compensated.
.
#Rhythm
Post MI < 48 hrs patient had several episodes of NSVT however
these resolved over time and with beta blockade titration as
well as electrolyte repletion.
.
#Hyperlipidemia
Atorvastatin 80 mg was provided and should be continued as an
outpatient.
.
Patient remained hemodynamically stable and afebrile during
admission.  He should follow up with Dr. [**Last Name (STitle) **] (cardiology),
his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1699**], and CT surgery.  He should continue to take
coumadin and have his INR followed by either his PCP or
cardiologist.  He should no longer take norvasc or
hydrochlorothiazide.  Aspirin was increased to 325 mg daily.
Beta blockade was increased to toprol xl 100 mg daily.
Atorvastatin was increased to 80 mg from 10 mg daily.

Medications on Admission:
Diovan/HCTZ 160/12.5'
Atenolol 50'
Lipitor 10'
Norvasc 5'
Aspirin 81


Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1)  Subcutaneous
[**Hospital1 **] (2 times a day) for 5 days.
Disp:*5 5* Refills:*1*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary:
myocardial infarction
CAD - three vessel disease
HTN
hypercholesterolemia


Discharge Condition:
good


Discharge Instructions:
You were admitted to the hospital with a heart attack (ST
elevation myocardial infarction).  You had a heart
catheterization which showed blockage of the LAD (left anterior
descending artery) as well as the other arteries of the left
coronary artery.
.
You should continue to take your medications as prescribed.  You
will need to follow up the cardiothoracic surgeon as well as
your PCP and cardiologist.
.
If you have recurrent chest pain, shortness of breath, excessive
bleeding, you feel light-headed or dizzy with standing, or
bloody / dark black foul smelling stolls please return to the
emergency room or call your PCP.

Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-12**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2205-9-12**] 11:00
.
Cardiothoracic Surgery - you must call to make an appointment
.
Primary care doctor
.
Cardiology - [**Doctor Last Name **], in [**Location (un) 620**]: ([**Telephone/Fax (1) 8937**], 3PM, [**2205-8-28**]
.
Cardiology


.H/O pulmonary edema
   Assessment:
   Rd the pt on CPAP 40%/peep 5/PS 10.LS clear with diminished base.BP in
   90
s systolic.K 3.4.Pt tachycardic in 120
   Action:
   Intense diuresis with lasix gtt, aiming for 200cc/hr UO.On levophed
   0.04 to keep MAP >60.EKG done with no significant change.
   Response:
   Pt is net 950cc neg for last 24hrs.Lasix gtt stopped till further
   evaluation.Conts on CPAP.Weaned levophed off.BP in 130
s with levophed
   off.repleted K
   Plan:
   Monitor BP and resp status.Lasix as needed.
   SIRS
   Assessment:
   Pt febrile to 101.5 axillary.WCC upto 12.3
   Action:
   BC sent, Tylenol given.
   Response:
   Temp down to 99.6.
   Plan:
   Follow culture data and temp curve.Follow wcc.


56 y/o male  with H/O DM, ESRD, on HD recently admitted with high grade
   enterococus faecalis bactermia,discharged AMA 48 hrs ago now
   readmiitted   with fever and SOB  found to have likely pul
   abcess/septicembolus.
   Renal failure, End stage (End stage renal disease, ESRD)
   Assessment:
   ESRD on HD 3x/wk last HD on [**7-8**] Bun /cre 49/11.2 k4.7 Po4 5.2
   Action:
   Response:
   Pt was heamodinamically stable since admission.
   Plan:
   Renal consult,HD as per schedule
   Impaired Health Maintenance
   Assessment:
   56 y/o man reported to be non complaint and frequently signs out of
   hospital AMA(dissatisfaction with care and social and financial
   factors,wife is HCP.
   Action:
   Requested for social work consult
   Response:
   Awaiting for the consult
   Plan:
   F/U with social work recommandations.Psych consult for sec 12 for
   admission and depressed with hospitalization.
   LS are dim at bases sats 100% on RA
   AO X 3,independent with care sitting at edge of the bed and OOB  to
   commode with minimum assist
   HR 90
s NSR,NBP 100-110/60-70 HD catheter @ LSC
   Abdomen obese on DM/renal diet tolerating well,BM X 1
   Dialysed yesterday.
   Demographics
   Attending MD:
   [**Doctor Last Name **] [**Doctor Last Name **] D.
   Admit diagnosis:
   BACTEREMIA
   Code status:
   Full code
   Height:
   72 Inch
   Admission weight:
   142 kg
   Daily weight:
   Allergies/Reactions:
   Ibuprofen
   Shortness of br
   Precautions:
   PMH:  Diabetes - Insulin, HEMO or PD, Renal Failure
   CV-PMH:  CAD, Hypertension, MI
   Additional


history:


Afib/Aflutter s/p ablation in [**2173**]
   AV fistula in R arm - s/p clot in fistula and thrombectomy
   diverticulosis on colonoscopy [**2174**]
   frequent eloping from hospital and leaving AMA
   Surgery / Procedure and date: s/p ablation in [**2173**]
   Latest Vital Signs and I/O
   Non-invasive BP:
   S:111
   D:71
   Temperature:
   97.9
   Arterial BP:
   S:
   D:
   Respiratory rate:
   18 insp/min
   Heart Rate:
   95 bpm
   Heart rhythm:
   SR (Sinus Rhythm)
   O2 delivery device:
   None
   O2 saturation:
   93% %
   O2 flow:
   2 L/min
   FiO2 set:
   24h total in:
   296 mL
   24h total out:
   0 mL
   Pertinent Lab Results:
   Sodium:
   138 mEq/L
   [**2178-7-9**] 04:08 AM
   Potassium:
   4.7 mEq/L
   [**2178-7-9**] 04:08 AM
   Chloride:
   100 mEq/L
   [**2178-7-9**] 04:08 AM
   CO2:
   25 mEq/L
   [**2178-7-9**] 04:08 AM
   BUN:
   49 mg/dL
   [**2178-7-9**] 04:08 AM
   Creatinine:
   11.2 mg/dL
   [**2178-7-9**] 04:08 AM
   Glucose:
   110 mg/dL
   [**2178-7-9**] 04:08 AM
   Hematocrit:
   25.3 %
   [**2178-7-9**] 04:08 AM
   Finger Stick Glucose:
   240
   [**2178-7-9**] 12:00 PM
   Valuables / Signature
   Patient valuables: eye glasses
   Other valuables:
   Clothes:  Sent home with: wife
   [**Name (NI) 50**] / [**Name2 (NI) 560**]:
   No money / [**Name2 (NI) **]
   Cash / Credit cards sent home with:
   Jewelry: yellow colored finger ring
   Transferred from: Fn4-404
   Transferred to: 1187
   Date & time of Transfer:  [**2178-7-9**] 1415


SICU NPN
ROS:
Neuro: No changes made in sedation overnight, pt appears comfortably sedated. Pt was noted to have eyes open this AM, not tracking in room or following commands. Pt with weak gag and cough, no spont movements noted.

CV: Stable overnight on pressors- levo titrated down, vasopressin unchanged-see carevue for doses- MAPS 65-75 all night. CVP 14-19; HR 60-70's, SR with occ PACs.. Heparin gtt at 1800 all night, PTT stable on that dose and will f/u in AM.  Pt also continues on amiodarone gtt. No P-boots on due to ?cellulitis in BLE and pt is antiocoaggulated on heparin. Multiple central lines and a-line sites intact, small ammt bloody drainage noted. Extremties edematous, but weakly palpable pulses noted.

Resp: Lungs coarse, diminished in bilat bases. Pt suctioned Q3-4 hours for thick, blood tinged sputum.  No vent changes made overnight. Pt with occasional drop in sats to 92% but recooperates independently. ABGs stable with PCO2 <60.

GI: Abd distended, hypoactive BS throughout. NGT to LWS, clamped after meds (ursidiol) Dulc suppos given with no immediate results.  LFTs/Bili noted to be elevated this AM, sicu team notified.  Pt continues on TPN with lipids. Protonix for GI prophylaxis.

GU/renal/CVVHD: Pt with no u/o overnight. Pt continues on CVVHD with no complications overnight, see flowsheet for pressures and fluid removal. System remains intact, no clots/air seen in tubing/filter.  Calcium gtt unchanged, see flowsheet for lab trends.

Endo: Insulin gtt titrated for sugars, see flowsheet for gtt/labs.

ID: WBC elevated to 22.8 this AM. No changes in abx.

Skin: Pt continues with cellulitic looking rash on BLE. Nystatin cream and steroid creams applied to multiple reddned rashy areas. See flowsheet for skin assessment. Pt continues on triadyne bed. Large ammt generalized edema noted.

Social: No family contact overnight.


[**2199-1-24**] 4:36 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 1**] # [**Clip Number (Radiology) 44493**]
 Reason: ETT position
 Admitting Diagnosis: ALTERED MENTAL STATUS;PNEUMONIA;DEHYDRATION
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


[**Age over 90 **] year old woman with pneumonia, s/p intubation


REASON FOR THIS EXAMINATION:


ETT position
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Pneumonia, status post intubation.  Check endotracheal tube
 position.

 PORTABLE AP CHEST:  Comparison is made with the study from 8 hours earlier.
 The newly inserted endotracheal tube tip is approximately 2 cm above the
 carina.  Cardiac size and engorged pulmonary vasculature/perihilar opacities
 are unchanged.  There are stable small bilateral pleural effusions.  The NG
 tube tip is in the stomach.


IMPRESSION:


Endotracheal tube tip 2 cm from carina. Unchanged CHF


[**2143-1-23**] 11:09 AM
 KNEE( (SINGLE VIEW) LEFT; AP WRIST & HAND LEFT                  Clip # [**Clip Number (Radiology) 46216**]
 Reason: r/o sphyllis,  exclude skull films
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


Infant with r/o syphilis


REASON FOR THIS EXAMINATION:


r/o sphyllis,  exclude skull films
 ______________________________________________________________________________


FINAL REPORT


INDICATIONS:    Maternal history of syphillis, infant with RPR negative.

 The bones of the left knee and left hand and wrist are normal.  Specifically
 the metaphyses have a normal appearance.


Newborn Med Attending

Swithched from HFO to SIMV yesterday. On 24/6 x 22, 50% O2. CXR showed decrease in PIE/hyperinflation. AF flat, coarse BS, + murmur, abd soft, MAE. On phototherapy. TF~130 cc/kg/d PN and IL. 2DE shoes no PDA, probable PPS.
A/P: Infant with severe CLD. Cont to wean from vent as tolerated. Consider re-starting trophic feeds.


NPN M/SICU ICU day 2
Events:  Succesfully extubated this AM.  Transfused 1 Unit [**Name (NI) **], pt remained afebrile throughout shift.

Review of Systems:

Neuro:  Aphasic at baseline, PEARL does not track or follow commands. Severe contractures unable to MAE.

CV: Stable throughout shift, HR 80's - 100, BP 90's-120/50-70's, refer to flowsheet for further detail

Resp:  Successfully extubated @ 10:00, LS clear throughout

GU/GI:  1.4 L pos. for 24hr, 3 L pos for LOS, Indwelling foley draining adeq amts clr/yellow urine. Abd soft nontender w/ +BS, -BM for shift

Access: R IJ TLCL, 2 PIV L hand/forearm

Plan:  ? PT/OT consult, cont. monitor and maintain hemo/resp status.  Restart [**Hospital 7240**] Transfer to medical bed when available


[**2177-5-30**] 8:46 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 107429**]
 Reason: interval eval
 Admitting Diagnosis: PE;AORTIC DISSECTION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


79 year old woman with left lower lobe collapse


REASON FOR THIS EXAMINATION:


interval eval
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


79-year-old female with left lower lobe collapse.  Evaluate for
 interval change.


COMPARISON:


[**2177-5-27**].


FINDINGS:


There is no significant change and decreased volume and left basal
 opacity consistent with left lower lobe collapse.  Bilateral small pleural
 effusions are unchanged with subsegmental right basilar atelectasis.  The
 pulmonary vasculature is normal.  The cardiac and mediastinal contours are
 notable for enlargement of the aortic knob contour, consistent with known
 dissection. Retrocardiac opacity likely reflect a combination of atelectasis
 and known large hiatal hernia.


IMPRESSION:


1.  Unchanged left lower lobe collapse.
 2.  Abnormal aortic knob contour, consistent with patient's known aortic
 dissection is not enlarging.


Admission Date:  [**2149-10-30**]              Discharge Date:   [**2149-11-8**]

Date of Birth:  [**2077-6-28**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain

Major Surgical or Invasive


Procedure:


[**2149-11-3**] Five Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending,
with saphenous vein grafts to diagonal, ramus intermedius,
obtuse marginal and PDA.
[**2149-10-30**] Cardiac Catheterization


History of Present Illness:
Patient is a 72-year-old male with h/o HTN, CAD s/p 3 stents in
[**2143**], hyperlipidemia, diabetes, and neurofibromatosis who
presented from OSH for cardiac catheterization.  Patient was
admitted to [**Hospital6 2910**] on [**2149-10-28**] for elective
microdiscectomy.  Shortly after the surgery, as the patient was
being transferred to his bed, he experienced sudden chest pain.
He stated that the pain was [**6-29**], substernal, non-radiating, and
relieved after 15 minutes by SL NTG.  The patient denies any
other associated symptoms.  ECG performed at the time showed
signs of ischemia, and the patient was found to have a NSTEMI
with a Troponin I of 24.  He underwent a cardiac catheterization
on the day before admission, where they found a 70% in-stent
restenosis of LCX, a ostial LAD lesion that was very difficult
to lay out, 50% left main disease and an occluded RCA with left
to right collaterals.  The patient was angiosealed and was
transferred to [**Hospital1 18**] for IVUS and pressure wire of the Left
Main.
.
Of note, the patient also has a history of left arm weakness in
[**2149-7-21**], which was thought to be a cryptogenic TIA vs a
stroke due to a small PFO.  The patient was thus started on
Coumadin. On review of systems, the patient denies any prior
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.


Past Medical


History:


Coronary Artery Disease, prior PCI/stenting [**2143**]
Hypertension
Dyslipidemia
Type II Diabetes
Back surgery
Macular degeneration
GERD
Atrial fibrillation
Patent Foramen Ovale, s/p TIA
Hypothyroidism
Neurofibromatosis


Social


History:


The patient lives outside of [**Location (un) 86**] with his wife.  [**Name (NI) **] smoked in
the past but quit 22 years ago.  He drinks alcohol occasionally.



Family


History:


The patient states that his younger sister had a CABG [**52**] years
ago.  His mother had angina.  His father died from a stroke.


Physical


Exam:


Admission PE
VS - T 99.7, BP 120/52, P 62, R 18, O2 97% on RA
Gen: Elderly man, pleasant, in NAD.  He was oriented x3 and his
mood and affect were appropriate.
HEENT: PERRL, EOMI.  Sclera anicteric. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.  Poor
dentition.  Multiple neurofibromas on inferior aspect of face.
Neck: Supple, no LAD.  No JVD appreciated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.  Femoral catheter site c/d/i
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Multiple neurofibromas on torso, neck, and face.
Pulses:  Right: DP 2+ PT 2+ , Left: DP 2+ PT 2+


Pertinent Results:
[**2149-10-30**] 09:40PM BLOOD WBC-7.6 RBC-3.31* Hgb-10.8* Hct-30.4*
MCV-92 MCH-32.7* MCHC-35.6* RDW-12.4 Plt Ct-139*
[**2149-10-30**] 09:40PM BLOOD PT-13.8* PTT-28.5 INR(PT)-1.2*
[**2149-10-30**] 09:40PM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-136
K-3.6 Cl-101 HCO3-29 AnGap-10
[**2149-11-2**] 06:10AM BLOOD ALT-22 AST-26 LD(LDH)-236 AlkPhos-55
TotBili-0.7
[**2149-10-30**] 09:40PM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9
[**2149-10-31**] 09:10AM BLOOD %HbA1c-5.9
[**2149-10-31**] Transthoracic ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
70%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2149-10-31**] Carotid Ultrasound:
Mild bilateral plaque with bilateral 1-39% ICA stenosis by
duplex criteria. Normal vertebral flow.
[**2149-11-3**] Intraop TEE:
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
The interatrial septum is redundant and hyperdynamic. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. Normal systolic
fxn.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.

Post-CPB:
Patient is on no infusions, NSR.
Preserved biventricular systolic fxn. No MR, No AI. Aorta
intact.

[**2149-11-8**] 06:50AM BLOOD Hct-33.3*
[**2149-11-7**] 05:25AM BLOOD WBC-7.8 RBC-3.24* Hgb-10.3* Hct-29.2*
MCV-90 MCH-31.7 MCHC-35.2* RDW-14.6 Plt Ct-190
[**2149-10-30**] 09:40PM BLOOD WBC-7.6 RBC-3.31* Hgb-10.8* Hct-30.4*
MCV-92 MCH-32.7* MCHC-35.6* RDW-12.4 Plt Ct-139*
[**2149-11-7**] 05:25AM BLOOD PT-15.3* INR(PT)-1.4*
[**2149-11-7**] 05:25AM BLOOD Glucose-97 UreaN-19 Creat-0.8 Na-137
K-4.4 Cl-101 HCO3-31 AnGap-9
[**2149-10-30**] 09:40PM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-136
K-3.6 Cl-101 HCO3-29 AnGap-10
[**2149-11-2**] 06:10AM BLOOD %HbA1c-6.1*
[**2149-10-31**] 09:10AM BLOOD %HbA1c-5.9

Brief Hospital Course:
Mr. [**Known lastname 18741**] was admitted from the [**Hospital **] Hospital with a non-ST
elevation myocardial infarction. He was loaded with Plavix and
underwent cardiac catheterization which again confirmed severe
three vessel coronary artery disease. Given the findings,
cardiac surgery was consulted and further preoperative
evaluation was performed. Echocardiogram showed normal LV
function and only mild mitral regurgitation. Carotid ultrasound
found only mild disease of the internal carotid arteries. His
preoperative chest x-ray revealed an approximately 5 mm rounded
nodular opacity in the lingula that could represent a pulmonary
nodule.
Preoperative course was otherwise uneventful. He remained pain
free on medical therapy.

On [**2149-11-3**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please refer to
operative note. Following the operation, he was brought to the
CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
received IV vancomycin for 4 doses post-operatively because he
was hospitalized for greater than 24 hours pre-operatively.  He
maintained stable hemodynamics and transferred to the SDU on
postoperative day one.

A chest CT scan was performed on POD 3 to evaluate the 5mm
nodule that was noted on his pre-op chest x-ray. Thoracic
surgery was consulted and they requested follow up CT scan in 6
months and follow up with [**Doctor Last Name 1533**], [**Name8 (MD) **] MD after the CT.

On post-operative day 5 he was stable and discharged to home.


Medications on Admission:
HOME MEDS:
Aspirin 81 mg daily
Warfarin 7.5 mg daily except 2.5 mg on Sunday
Reglan 10 mg q6h prn
Lipitor 80 mg daily
Tenormin 75 mg daliy
Prevacid 30 mg daily
Zestril 10 mg daily
Synthroid 150 mg daily
Multivitamin daily
Vitamin E [**2140**]
Vitamin C 500 mg daily
Duragesic 15 mcg q72 h
Flonase 1 spray daily
NTG SL prn

TRANSFER MEDS:
Magnesium oxide 800 mg
MVI
Nitrobid 1 inch q 6
Plavix 300 mg at 9:15 am
ASA 325 mg
Duagesic at 25 mcg
Flonase
Lopressor 25 mg q 8
Protonix
Vitamin C
Vitamin E
Zestril 10mg


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
12. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Dr
[**Last Name (STitle) 58805**] will adjust your INR.
Disp:*30 Tablet(s)* Refills:*0*
13. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day.
Disp:*120 Tablet(s)* Refills:*0*
14. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]

Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Recent NSTEMI
Hypertension
Atrial Fibrillation
Dyslipidemia
Type II Diabetes Mellitus
Cerebrovascular Disease
Neurofibromatosis


Discharge Condition:
Good


Discharge Instructions:
1)  Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2)  Report any fever greater then 100.5.
3)  Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4)  No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry.  Please shower daily.  No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.

Followup Instructions:
Dr. [**Last Name (STitle) **] in [**2-22**] weeks, call for appt
Dr [**Last Name (STitle) 1533**], [**Name8 (MD) **] MD in 6 months
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40740**] or Dr. [**Last Name (STitle) **](cardiology) in [**12-22**] weeks, call for
appt
Dr. [**Last Name (STitle) 58805**](PCP) in [**12-22**] weeks, call for appt
 - Dr [**Last Name (STitle) 58805**] will continue to follow his INR (spoke with [**Doctor Last Name **])
 - [**Doctor Last Name 269**] to fax INR results to ([**Telephone/Fax (1) 81621**]
Will need a follow-up CT scan in 6 months for 5mm nodule seen on
chest CT



Completed by:[**2149-11-8**]


CVICU
   HPI:
   HD2   POD 15-tvr/cabg
   Ejection Fraction:55
   Hemoglobin A1c:7
   Pre-Op Weight:0 lbs   0 kgs
   Baseline Creatinine:1.0
   PMH: HTN, Hypercholesterolemia, CAD s/ pMI s/p 4 stents/[**Hospital1 12**] ([**2161**]),
   GERD, Depression/Anxiety, h/o prescription narcotic addiction, Uterine
   CA in her 20s, remote hx PE, Restless leg syndrome, CVA, s/p Tricuspid
   valve replacement (porcine) for Staph endocarditis 20 years ago, s/p
   tonsillectomy, s/p cholecystectomy, s/p hysterectomy, s/p tubal
   ligation, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 91**] for small bowel obstruction, s/p abdominal
   re-constructive surgery
   [**Last Name (un) **]:ASA 81mg daily, toprol 150', Cymbalta 30', Diltiazem XT 120',
   Lisinopril 10', Protonix 40', HCTZ 25', Premarin 0.3', Vitamin E 400',
   Simvastatin 10', Ropinirole 0.5', Benzonate 200/PRN,Lorazepam 0.5/PRN,
   Advil/Tylenol,Benadryl PRN
   Assessment:62yoW s/p Redo sternotomy TVR(#27 [**Company 346**] Mosaic
   tissue)CABG x4(SVG-LAD,SVG-Diag,SVG-OM, SVG-PDA)[**2-11**]
   Plan:Discharged to rehab [**2-22**], readmitted for
   PNA on [**2-25**]
   Current medications:
   Albuterol 0.083% Neb Soln . Amiodarone . Aspirin EC . Bisacodyl .
   Ciprofloxacin HCl . Docusate Sodium
    Duloxetine8. Ipratropium Bromide Neb .Lorazepam Magnesium Sulfate .
   Metoprolol Tartrate Metoclopramide . Oxycodone-Acetaminophen .
   Pantoprazole Ropinirole . Simvastatin TraMADOL (Ultram)
   Post operative day:
   POD 15 TVR/CABG
   Allergies:
   Penicillins
   Tongue swelling
   Sulfa (Sulfonamides)
   Rash;
   Codeine
   Unknown;
   Prednisone
   Diarrhea;
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Other medications:
   Flowsheet Data as of  [**2182-2-26**] 08:58 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**83**] a.m.
   Tmax: 36.7
C (98.1
   T current: 36.2
C (97.1
   HR: 94 (92 - 117) bpm
   BP: 138/79(93) {73/18(20) - 165/136(157)} mmHg
   RR: 14 (12 - 23) insp/min
   SPO2: 94%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 55.1 kg (admission): 57 kg
   Height: 65 Inch
             Total In:
                                                                     70 mL
                                                                     40 mL
   PO:
             Tube feeding:
   IV Fluid:
                                                                     70 mL
                                                                     40 mL
   Blood products:
   Total out:
                                                                    370 mL
                                                                     50 mL
   Urine:
                                                                    370 mL
                                                                     50 mL
   NG:
   Stool:


Pt is 69 yo male found unresponsive sitting in bathroom by his son, .
   EMS-->>pt unresponsive to sternal rub, VSS. FS=133. In EW, Na 103, K
   2.6.  Pt woke gradually, A&Ox3, lethargic. CT head neg, CT abd->> lg
   inguinal hernia which contains bowel--no obstruction. Received 700cc
   NS, 60 KCL PO. Seen by renal-received -3%hypertonic Na @ 70cc/hr x 1
   hr, then rechecked Na @ 5
106, K 2.7 Transferred to MICU. 3% hypertonic
   NA @ 70cc/hr. Pt recently started trileptal for trigeminal neuralgia
   with severe dental pain,
10 days ago. Which is the probable cause of
   pts hyponatraemia therefore has been stopped at this time.
   Events: PT alert, answering orientation questions but cont confused
   about year.  In AM OOB to chair w/ minimum RN assist- * high falls risk
   w/ recent fall.  No dizziness, appropriate change in VS.  2 PIV, R IJ
   pulled, L Aline pulled.
   .H/O anemia, other
   Assessment:
   Am HCt decreased to 23  w/ recent variable HCt since admission,
   Action:
   Repete iron studies ordered
   Response:
   No s/s bleeding,
   Plan:
   Guiac all stool
   Hypokalemia (Low potassium, hypopotassemia)
   Assessment:
   0800 K 4.4
   Action:
   No repletement
   Response:
   Plan:
   Changed from Q4 to Q 8 hrs lab draws
   Bradycardia
   Assessment:
   HR 50
s SB to 70
s SR w/ rare-occ missed bts, variable to activity, pt
   alert, mentating, low dose Dopamine gtt weaned off [**10-24**]
   Action:
   Cont monitoring
   Response:
   Plan:
   Cont monitoring HR/rythm
   Diarrhea
   Assessment:
   Resolved- needs 3^rd stool sample to R/O C-Diff
   Action:
   Response:
   Plan:
   Obtain 3^rd stool sample
   Hyponatremia (low sodium, hyposmolality)
   Assessment:
   0800 NA 130- from previous 130, no s/s hyponatremia, no paristhesia,
   mentating well
   Action:
   Cont NS @ 100cc/hr for 1 L, neuro monitoring, monitoring and teaching
   s/s hyponatremia
   Response:
   No change over shift
   Plan:
   Cont NS @ 100cc/hr x 1 L, high salt PO, hold free water


Alteration in Elimination Related to Constipation
   Assessment:
   Pt with no bowel mvmt x multiple days. Admitted on [**11-3**]. Abd
   distended/soft, hypoactive BS.
   Action:
   Pt on a bowel regimen, prn MOM/Lactulose/Senna all given. TF at goal ,
   no residuals. Methylnaltrexone administered SQ.
   Response:
   Medium mucoid stool this evening, nothing felt on digital exam.
   Plan:
   Continue bowel regimen.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 76**])
   Assessment:
   Pt ventilated via # 8 portex trach. Pt on psupp [**7-7**].  LS rhonchorus
   throughout, intermittent inspiratory wheezing. RR initially 18-20,
   suctioning for copious amounts of thin white secretions orally and when
   deep suctioning. Sats 96-98%. Around 1400 pt a bit more anxious,
   stating he couldn
t breath. Saturation 99% but then began to drop as
   low as 93% with a rr 33. Respiratory up to eval, settings changed to
   [**7-11**] with much improvement. Pt feels breathing better. Arterial line
   failed this evening, unable to obtain gas.
   Action:
   Trach care, oral care. Vap protocol. Lasix 20 mg. Following cxrays.
   Speech by today to follow up with PMV valve, but pt unable to use
   currently due to resp status. Xanax for anxiety. ATC nebulizers.
   Arterial stick done by MD.
   Response:
   Pt appears to be more comfortable. RR now back to 18 bpm on [**7-11**] mv 13
   liters/min. Weaned to [**7-9**] cont with metabolic alkalosis.  saturation
   back to 97%
   Plan:
   Continue to gently diurese. Suction as needed. Spot gas
s. re-insert
   aline later tonight or tomorrow per resident.
   Trauma, s/p MVC car vs wall
   Assessment:
   Pt afebrile, quadriplegic. Off anbx. Pt with multipodis on,  teds
   applied. Hx of spinal shock/ c3/6 cord contusion. Off Neosynephrine, on
   midrodrine. Maps > 60. IVC filter in past. Pt still needs to go to OR
   to have hip/femur fixed in few months. Pain to neck, [**Location (un) 408**] J on. Vss,
   occasionally will vagal. No issues for this RN. If continues cards may
   need to be consulted. Plan for picc placement for long term access. TF
   at goal via peg.
   Action:
   Turn and reposition. Encourage oob via use of [**Doctor Last Name 485**]/lift. PT & OT
   consult for call bell. Skin care. CPT as tolerates. Gentle diuresis.
   Await picc placement. Continue TF, check residuals.
   Response:
   No changes, remains stable. Picc line placed at 1700, followed up with
   cxray. Await confirmation of placement.
   Plan:
   Cont with care, await confirmation of placement.
   Ineffective Coping
   Assessment:
   Hx of anxiety/? Bipolar d/o. Pt becoming more withdrawn, refusing to
   see visitors. Hx of anxiety,on xanax at home. New diagnosis quad. No
   family, pt has friends, one of which is HCP.
   Action:
   Suggested to team anti-depressant.
   Response:
   No changes, emotional support provided
   Plan:
   Cont to monitor.


PATIENT/TEST INFORMATION:


Indication:


Intraoperative TEE for MVR, AVR, MAZE
Status: Inpatient
Date/Time: [**2154-5-29**] at 10:56
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: Moderate LA enlargement. Elongated LA. Mild spontaneous echo
contrast in the body of the LA. Moderate to severe spontaneous echo contrast
in the LAA. Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA.
All four pulmonary veins identified and enter the left atrium.

RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.

LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D
images. Normal LV wall thickness, cavity size, and global systolic function
(LVEF>55%).

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Simple atheroma in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending aorta.

AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve
leaflets. Moderate-severe AS (area 0.8-1.0cm2). Mild (1+) AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets. Characteristic
rheumatic deformity of the mitral valve leaflets with fused commissures and
tethering of leaflet motion. Mild mitral annular calcification. Mild
thickening of mitral valve chordae. Moderate valvular MS (MVA 1.0-1.5cm2)
Severe valvular MS (MVA <1.0cm2). Mild to moderate ([**1-9**]+) MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic
(normal) PR.

PERICARDIUM: Trivial/physiologic pericardial effusion.

GENERAL COMMENTS: A TEE was performed in the location listed above. I certify
I was present in compliance with HCFA regulations. The patient was under
general anesthesia throughout the procedure. No TEE related complications. The
rhythm appears to be atrial fibrillation. Results were personally reviewed
with the MD caring for the patient.

Conclusions:
PRE CPB The left atrium is moderately dilated. The left atrium is elongated.
Mild spontaneous echo contrast is seen in the body of the left atrium.
Moderate to severe spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s).
No definitive thrombus is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple atheroma in the
aortic arch. The descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened. There is
moderate to severe aortic valve stenosis (area 1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately thickened. The
mitral valve shows characteristic rheumatic deformity. There is moderate to
severe valvular mitral stenosis (area 1.0 cm2). Mild to moderate ([**1-9**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly thickened.
There is mild tricuspid regurgitation. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 43**] was notified in person of the results in the
operating room at the time of the study.

POST CPB Patient is being atrially paced. Normal biventricular systolic
function. Bioprosthesis in the mitral position is oriented towards the left
ventricular outflow tract but is well seated. Leaflet motion is normal. There
is trace valvular mitral regurgitation. The maximum pressure gradient across
the mitral valve is 13 mm Hg with a mean pressure gradient of 4 mm Hg at a
cardiac output of 6.5 l/m. There is a bioprosthesis located in the aortic
position. It is not well seen but it does appear well seated with normal
leaflet function. There is at least trace valvular aortic regurgitation but
shadowing and poor echo windows prevent full assessment of the regurgitation.
The maximum pressure gradient across the aortic valve is 14 mm Hg. The left
atrial appendage has been resected. The thoracic aorta appears intact.


Atrial fibrillation. Since the previous tracing of [**2172-12-18**] the rate is slower.
Otherwise, no diagnostic change.


54 yo F w/RA (on plaquenil and celebrex) and breast ca metastatic to
   brain (s/p recent craniotomy) and bone admitted from rehab after found
   to be hypotensive and lethargic.  BP fluid responsive; never required
   pressors.  Suspect hypotension [**1-17**] infection + hypovolemia in setting
   of several days of diarrhea.  ([**Last Name (un) **] stim appropriate (had been on
   intermittent steroids w/chemo), CvO2 85, TTE hyperdynamic).  Dirty U/A
   (cx pending, has had proteus in past) and c diff positive- on cefepime
   and flagyl.  Lethargy likely [**1-17**] HOTN + med effect, now improved.
   Non-gap metabolic acidosis post NS resuscitation; LR if need to bolus.
   Persistent ST on unclear [**Name2 (NI) **]- making excellent urine, so don't think


[**2173-5-28**] 5:04 AM
 CHEST (SINGLE VIEW)                                             Clip # [**Clip Number (Radiology) 49517**]
 Reason: acute CT process?
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


59 year old man with trip and fall eval for acute CT process


REASON FOR THIS EXAMINATION:


acute CT process?
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


59-year-old male status post fall.


COMPARISON:


[**2172-2-4**].


FINDINGS:


AP supine chest radiograph is submitted for review.  The lungs are
 clear.  There is no consolidation, effusion, or pneumothorax.  The pleural
 surfaces are smooth.  Accounting for technique, there is no acute  hilar and
 cardiomediastinal contour abnormality.  However, there is fullness of the
 right paratracheal border and adjacent tracheal irregularity, which could
 represent adenopathy, though is suboptimally evaluted on this AP supine study.
 There are no displaced rib fractures identified.  Visualized thoracic
 vertebral bodies are normal in height.


IMPRESSION:


1.  No acute cardiopulmonary process.
 2.  Right paratracheal stripe fullness may represent adenopathy.  Further
 evaulation with AP and lateral chest radiographs is recommended.

 As the patient had been discharged from the ED at the time of interpretation,
 the ED QA staff were notified of the need for follow-up.


63 years old male with PMHX: CAD,NTH,DM,Colon Ca,PTCA,past Echo 65%,DX: CAD,S/P CABG *3. Patient on mechanical ventilation,Bs diminished will continue to follow.


Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with
secondary repolarization changes. Compared to the previous tracing
of [**2125-6-7**] no significant diagnostic change.


[**2200-3-4**] 1:41 PM
 FOOT AP,LAT & OBL BILAT                                         Clip # [**Clip Number (Radiology) 54684**]
 Reason: Evaluate for osteomyelitis
 Admitting Diagnosis: DEHYDRATION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


79 year old woman with bilateral pedal ulcers


REASON FOR THIS EXAMINATION:


Evaluate for osteomyelitis
 ______________________________________________________________________________


FINAL REPORT


THREE VIEWS OF EACH FOOT


INDICATION:


Bilateral pedal ulcers.  Evaluate for osteomyelitis.


FINDINGS:


LEFT FOOT:

 There is no evidence of bony destruction.  There is no radiographic evidence
 of osteomyelitis.  Note is made of degenerative change at the intertarsal
 joints and at the first tarsometatarsal joint.  There is a plantar calcaneal
 spur.  No focal bone lesion is identified.

 RIGHT FOOT:

 There is no evidence of fracture.  There is no evidence of cortical
 destruction.  There is no radiographic evidence of osteomyelitis.  There is
 degenerative change at the first tarsometatarsal joint.  There is a plantar
 calcaneal spur.


IMPRESSION:


No evidence of osteomyelitis in either foot.  Bilateral first TMT DJD.
 Bilateral plantar calcaneal spurs.


TITLE:
   55 yo F unrestrained driver, s/p single car MVC into guardrail, +airbag
   deployment.  Awake, confused at scene, likely ETOH, blood glucose 106.
   Intubated at OSH for combattiveness/airway protection. Has facial
   fractures, got nasal packing, left lateral canthotomy. Pupils unequal.
   Got 2 units uncrossmatched blood prior to [**Location (un) **] transfer for low
   bp. In ED, ? small pericardial effusion on FAST, got 1 more unit
   unmatched blood.
   Trauma, s/p mvc
   Assessment:
   Action:
   Response:
   Plan:


1900-2300. Pt remains comfortable with propofol at 60mcg/kg/min. Awakes to tactile/verbal stimuli. Hemodynamically stable, nipride gtt titrated down to 4mcg/kg/min with sbp <160. Dressings to incisions clean and dry, old staining noted. All else as per careview.


NPN 7p-7a


Resp: RA, sats 97-100%. LS clear, RR 40-70s, mild SC
retractions. Some periodic breathing noted. Recieving PO
caffiene, one spell w/ spit at end of gavage feed. Mild stim
and bulb suctioned mouth.

FEN: Weight 1685, up 20g. TF 140cc/k/d of PE26 w/PM; 30cc q
3hrs gavaged over ~1hour. Attempting to ween to 50min, only
one small spit so far this shift. HOB at 15degrees for
reflux. Abd benign, BS active. V&S, guiac neg. Tolerating
feeds, con't as planned and monitor.

G&D: Alert and active, sleeping well. Temps stable, was
nested in low air isolette, now swaddled in off isolette,
maintaining stable temps. Transfering to [**Hospital1 **] tomorrow.
Con't to support dev needs.

Parenting: No contact w/ [**Name2 (NI) **] so far this shift. [**Name2 (NI) 8**]
are aware of transport tomorrow, need to get transport
consent from them. Con't to support and update as needed.


update
D: pt s/p cabg- lido to off this am, swan d/c, fem aline d/c- periph iv placed and cordis d/c (kinking).
neuro: pt lethargic-easily [**Last Name (LF) 842**], [**First Name3 (LF) **], pupils equal and rx to light.
resp: on 3l np with sat >97%, bs dim in bases, intermittent crackles noted and rhonchi- cl with coughing- inhaler cont, [**Location (un) **] care cont with assist.
cardiac: pt remians in afib with occas pvc's- same amt noted with lido on and lido off. palp pedal pulses, sbp- wnl.lopressor 12.5 mg cont.
gi: tol po's well, due to lethargy controled po intact- pt fed- difficulty holding spoon due to edema in hands and arms. abd soft, positive flatus.
gu: diuresing well with lasix 80mh po- k being replaced as needed.
activity; once fem aline d/c- pt oob to chair with max assist of 2, able to stand and support wt.
glu: following slifding scale for elevated glu-
plan: ??transfer to floor in am


Resp Care,
Pt. remains intubated currently A/C 500/22/.6/10peep. Suctioned bile from ET. Changed to A/C overnoc to rest. See vent flowsheet.


[**2175-7-23**] 9:45 AM
 CT ABD & PELVIS WITH CONTRAST                                   Clip # [**Clip Number (Radiology) 102374**]
 Reason: Evaluate for obstruction, bile leak, abscess, colitis
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


History:


72M with liver disease s/p ERCP p/w abdominal pain


REASON FOR THIS EXAMINATION:


Evaluate for obstruction, bile leak, abscess, colitis
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: SVMc SUN [**2175-7-23**] 11:12 AM
  1) d/c in the amount of intrahepatic dilatation. cont CBD dilatation, although
  this has also decreased slightly since the last study. s/p cholecystectomy,
  but dilatation still out of proportion.
  2) increase in the amount of ascites since the prior study, now extending to
  pericolic gutters.
  3) otherwise, stable appearance from [**7-15**]
 WET READ VERSION #1
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


This is a 72-year-old man with liver disease, status post ERCP,
 presenting with abdominal pain.


TECHNIQUE:


CT of the abdomen and pelvis with IV contrast was performed.


COMPARISON:


[**2175-7-15**], reference CT.


FINDINGS:


CT OF THE ABDOMEN:  Bilateral lung bases are clear of worrisome
 nodules or effusions.  Minimal dependent atelectatic changes noted.  The
 imaged portion of the pericardium is unremarkable.

 Within the abdomen, liver enhances homogeneously with no focal liver lesions.
 The significant previously seen intrahepatic ductal dilatation has greatly
 resolved; however, there is still dilatation of the right and left hepatic
 bile ducts (2:23) as well as common bile duct up to 1.6 cm (601B:32). These
 are all slightly smaller than the prior study. There is fat stranding around
 the CBD, unchanged.  The patient is status post cholecystectomy.  The spleen
 is enlarged measuring up to 17 cm.  There is also significant systemic
 shunting with gastric and esophageal as well as splenic varices.  Small
 density in the spleen (2:18) is too small to characterize.

 There is generalized abdominal ascites, increased since the prior study
 measuring simple in density. The fluid is occupying the perisplenic,
 perihepatic as well as bilateral paracolic gutters.  The small bowel, stomach
 and large bowel themselves are unremarkable with the exception of significant
 diverticular disease in the patient's sigmoid, however, there is no evidence
 of diverticulitis.  Multiple celiac nodes present and unchanged; the largest
 is in the porta hepatis area measuring 2.7 x 1.0 cm (2:27), unchanged from the
 prior study.  Pancreas is fatty replaced, although grossly unremarkable.

 Bilateral kidneys enhance and excrete contrast symmetrically with no evidence
 of hydronephrosis or solid masses.  Hypodensity off the lower pole of the left
 kidney measures 3.0 x 2.7 cm, consistent with simple renal cyst.  Additional
                                                             (Over)

 [**2175-7-23**] 9:45 AM
 CT ABD & PELVIS WITH CONTRAST                                   Clip # [**Clip Number (Radiology) 102374**]
 Reason: Evaluate for obstruction, bile leak, abscess, colitis
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 hypodensities, including a 1.2-cm right upper pole lesion is also consistent
 with a simple renal cyst.  Several other smaller hypodensities are too small
 to characterize in the right kidney as well as the left.  Bilateral adrenals
 appear normal.

 CT OF THE PELVIS:  Rectum, seminal vesicles and prostate as well as bladder
 are unremarkable.  No pelvic free fluid is identified.  The appendix is not
 definitely visualized; however, no secondary signs of appendicitis are noted.

 BONES:  No suspicious lytic or sclerotic lesions are seen.  There are severe
 degenerative changes throughout the thoracolumbar spine.


IMPRESSION:


1.  Decrease in the amount of intrahepatic ductal dilatation with continued
 extra-hepatic ductal dilatation, although this is also slightly decreased in
 extent.
 2.  Increase in the amount of generalized ascites throughout the abdomen as
 compared to the prior study, low in total volume.
 3.  Sigmoid diverticulosis without any evidence of diverticulitis.
 4.  Splenomegaly as well as gastric, esophageal and splenic varices.


[**2174-9-19**] 2:48 PM
 PICC LINE PLACMENT SCH                                          Clip # [**Clip Number (Radiology) 41475**]
 Reason: please reposition r picc line
 Admitting Diagnosis: LEFT GROIN WOUND INFECTION
 ********************************* CPT Codes ********************************
 * [**Numeric Identifier 545**] EXCH PERPHERAL W/O [**Numeric Identifier 546**] FLUORO GUID PLCT/REPLCT/REMOVE   *
 ****************************************************************************
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


70 year old woman with R picc placed by iv team, not in correct position -
  please reposition


REASON FOR THIS EXAMINATION:


please reposition r picc line
 ______________________________________________________________________________


FINAL REPORT


PICC LINE EXCHANGE/REPOSITIONING


INDICATION:


Malposition of indwelling PICC line.

 The procedure was explained to the patient.  A timeout was performed.

 RADIOLOGIST:  Dr. [**Last Name (STitle) 582**] and Dr. [**Last Name (STitle) 50**] performed the procedure.


TECHNIQUE:


Using sterile technique and local anesthesia, a guide wire was
 advanced through the indwelling right arm PICC line, and subsequently into the
 SVC under fluoroscopic guidance.  The old PICC line was then removed, and a
 peel-away sheath was then placed over the guide wire.  A new single lumen PICC
 line measuring 48 cm in length was then placed through the peel-away sheath
 with its tip positioned in the SVC under fluoroscopic guidance.  Position of
 the catheter was confirmed by a fluoroscopic spot film of the chest.

 The peel-away sheath and guide wire were then removed.  The catheter was
 secured to the skin, flushed, and a sterile dressing applied.

 The patient tolerated the procedure well.  There were no immediate
 complications.


IMPRESSION:


Uncomplicated fluoroscopically guided PICC line exchange for a
 new single lumen PICC line.  Final internal length is 48 cm, with the tip
 positioned in the SVC.  The line is ready to use.


[**2177-5-1**] 4:08 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 114288**]
 Reason: s/p CABG, cardiac surgery patient, fast track extubation. Wi
 Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41 year old man s/p CABG


REASON FOR THIS EXAMINATION:


s/p CABG, cardiac surgery patient, fast track extubation. Will call upon
  admission to CVICU.
 ______________________________________________________________________________


FINAL REPORT


TYPE OF


EXAMINATION:


Chest AP portable single view.


INDICATION:


41-year-old male patient status post bypass surgery, fast track
 extubation protocol.


FINDINGS:


AP single view of the chest has been obtained with patient in
 supine position.  The patient is now intubated, the ETT terminating in the
 trachea 4 cm above the level of the carina.  A right internal jugular approach
 sheath carries a Swan-Ganz catheter, the tip of which reaches the central
 portion of the left pulmonary artery.  An NG tube reaches well below the
 diaphragm into the fundus of the stomach, including the side port.  Bilateral
 chest tubes advanced from below as well as two mediastinal drainage tubes are
 seen.  Lungs remain well expanded and no pneumothorax is identified.  No
 pulmonary congestive pattern.  With the exception of a thin plate atelectasis
 in the left base, no pulmonary abnormalities.


IMPRESSION:


Satisfactory first postoperative chest findings status post
 bypass surgery, no pneumothorax.


Respiratory care:
Patient remains on A/C ventilatory support with no parameter changes made throughout the night.  Morning abg results revealed normal acid-base balance with excellent oxygenation on the current settings.

No RSBI measured due to lack of spontaneous respirations at this time.


NPN 0700-[**2086**]
This RN assessed and agrees with the above note by [**First Name8 (NamePattern2) 347**] [**Last Name (NamePattern1) **]; co-worker.  [**Name (NI) **] in this afternoon and updated on plan of care.  Mother independent with infant cares.  Cont to support and update [**Name (NI) 32**].


[**2162-8-25**] 12:19 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 97484**]
 Reason: Evaluate for interval change
 Admitting Diagnosis: END STAGE RENAL DISEASE
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


81 year old woman with watershed infarct


REASON FOR THIS EXAMINATION:


Evaluate for interval change
 CONTRAINDICATIONS for IV CONTRAST:
  renal function and intracranial bleed
 ______________________________________________________________________________


FINAL REPORT


NON-CONTRAST HEAD CT SCAN


HISTORY:


Watershed infarct.  Evaluate for interval change.


TECHNIQUE:


Non-contrast head CT scan.

 COMPARISON STUDY:  MR scan of [**8-23**], reported as disclosing multiple small
 hemorrhagic embolic infarcts as well as the right thalamus and left pons, as
 dictated by Doctors [**Name5 (PTitle) 451**] and [**Name5 (PTitle) **].


FINDINGS:


At the present time, there are moderate-sized, wedge-shaped areas of
 low absorption at the borderzones between the posterior cerebral and middle
 cerebral artery territories bilaterally which appear to have evolved since the
 prior MR study.  These abnormalities are certainly consistent with bilateral
 watershed infarcts.  Multiple smaller areas, previously seen on the MR study
 as  hyperintense on the diffusion-weighted images and possibly having
 hemorrhagic contents are seen as low densities on the present CT scan.  They
 are consistent with infarctions, but any proported blood products would have
 to be subacute to chronic in age.  There is no hydrocephalus or shift of
 normally midline structures.  There is heavy atherosclerotic calcification
 involving the distal vertebral arteries at the level of the foramen magnum and
 to a lesser extent the distal portions of the cavernous carotid arteries.


IMPRESSION:


Border zone infarcts in the parietal-occipital regions
 bilaterally, with other findings, as noted above.


45 yr old man w/CML who was discharged from [**Hospital1 54**] on
, readmitted
   through EW [**2-11**] w/MS changes.  Oriented to self only.  Had head CT that
   showed new 6mm hyperdense focus @ L temporal lobe-?metastatic lesion vs
   small hemorrhage.  To get MRI  better diagnose.
   Respiratory failure, chronic
   Assessment:
   Continues on the vent with settings of PSV 10cm PEEP 5cm, with RR
   28-48, higher rates with agitation. sedation with propofol at initially
   40mcg/kg/hr stopped for neuro exam restarted one hour laters at
   50mcg/kg/hr.
   Action:
   With agitation gave 0.5mg of ativan, restarted propofol to 50mcg/kg/hr,
   Response:
   Improved ventilation with sedation
   Plan:
   His wean/ sedation plan has been contigent on plans for brain biopsy.
   He is a difficult airway will need anesthesia at bedside for
   extubation.
   Hypertension, benign
   Assessment:
   One episode of hypotension to 70/ after 10mg bolus of propofol,
   Action:
   Hypotension tx with 1liter of NS
   Response:
   BP up to 120-140/70
s HR down to 90-100
   Plan:
   Continue to monitor, is on labetalol 10mg Q 6hr.
   Transplant, bone marrow (BMT)
   Assessment:
   Pt originally admitted for mental status changes, and dyspnea, found to
   have 6mm hyperdense focus @ L temporal lobe, pt goes from sedated to
   very agitated. Does have rhythmic movements to hands at times, not
   following commands consistently, does try to mouth words activity level
   waxes and wanes.
   Action:
   Neuro consult, BMT service and MICU team feel pt needs brain biopsy,
   wife now has agreed.
   Response:
   Mental status slightly better than on admission but still waxes and
   wanes,
   Plan:
   Plan is neuro team will present pt on Monday so the biopsy will not
   occur til early next week. , coordinating when this might occur, will
   need MRI . With changes in mental status will load pt with phenytoin to
   prevent seizures.
   Wife at bedside since 12pm, asking very appropriate questions. Support
   by family  members.
   With drop in urine output, less than 30cc/hr,  with rise in creatine
   have given patient 1liter boluses of NS during the day for total of
   3liters with improvement  of urine output to 30-40cc/hr.  electrolytes
   pnd.


[**2130-2-18**] 4:12 PM
 MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE           Clip # [**Clip Number (Radiology) 57150**]
 MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST
 -52 REDUCED SERVICES
 Reason: evaluate for stroke
 Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC [**Last Name (un) **] PULM DISEASE
  Contrast: GADAVIST Amt: 2CC
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


58 year old woman with likely seizure, want to r/o stroke


REASON FOR THIS EXAMINATION:


evaluate for stroke
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


MRI AND MRA OF THE BRAIN AND MRA OF THE NECK (INCOMPLETE), [**2130-2-18**]


HISTORY:


58-year-old female with likely seizure; evaluate for stroke.


TECHNIQUE:


Routine [**Hospital1 51**] non-enhanced cranial MRI and MRA, with review of
 both axial source and rotational targeted MIP-reconstructed images from the
 MRA on the workstation.  Note:  Though a contrast-enhanced MRA of the cervical
 vessels was requested and attempted, according to the technologist's note "the
 patient cooperate(d) only with 'timing run' and then refused to continue."


FINDINGS:


The study is compared with the cranial MRI of [**2129-5-18**].  There is
 background multifocal and confluent FLAIR-hyperintensity in periventricular
 and central pontine white matter, unchanged, representing the sequelae of
 chronic small vessel ischemic disease.  However, there is now relatively
 symmetric [**Name (NI) **]/FLAIR-hyperintensity in bihemispheric parietal and occipital
 subcortical white matter.  This demonstrates only mild mass effect and
 allowing for T2- "shine-through" effect, there is no definite evidence of slow
 diffusion at these sites, or elsewhere in the brain.  There is no intra- or
 extra-axial hemorrhage, the midline structures are in the midline and the
 ventricles and cisterns are normal and unchanged in size and configuration.
 The remainder of the examination is notable only for a small mucus-retention
 cyst in the right sphenoid air cell, unchanged.

 There is normal flow-related enhancement in the included intracranial portions
 of both internal carotid and proximal middle and anterior cerebral arteries,
 with normal, symmetric arborization of MCA branches, bilaterally and no
 significant mural irregularity or flow-limiting stenosis.  There is normal
 flow-related enhancement in the distal vertebral arteries with dominant left
 vessel, as well as the basilar and bilateral superior cerebellar and posterior
 cerebral arteries, with no significant mural irregularity or flow-limiting
 stenosis.  There is no aneurysm larger than 3 mm in diameter.


IMPRESSION:


1.  Findings involving the parieto-occipital subcortical white matter,
 bilaterally, without significant mass effect or associated diffusion
 abnormality or hemorrhage.  These findings are most suggestive of so-called
 PRES (posterior reversible encephalopathy syndrome) and should be closely
 correlated with history of significant hypertension (including "relative"
                                                             (Over)

 [**2130-2-18**] 4:12 PM
 MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE           Clip # [**Clip Number (Radiology) 57150**]
 MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST
 -52 REDUCED SERVICES
 Reason: evaluate for stroke
 Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC [**Last Name (un) **] PULM DISEASE
  Contrast: GADAVIST Amt: 2CC
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 hypertension) and/or implicated pharmaceutical agents.
 2.  Discrete and confluent FLAIR-hyperintensity in bihemispheric subcortical
 and periventricular and central pontine white matter, unchanged since
 [**2129-5-18**], and likely representing chronic small vessel ischemic disease,
 perhaps related to underlying hypertension.
 3.  Unremarkable cranial MRA, with no flow-limiting stenosis.  N.B. The
 cervical MRA could not be completed.

 COMMENT:  These findings were discussed with Dr. [**First Name (STitle) 1990**] [**Name (STitle) 1991**] (HMFP hospitalist,
 caring for the patient), via telephone, at 1350H, [**2130-2-19**], who informed me
 that the patient is being treated for the clinical diagnosis of PRES.


[**Last Name (LF) 2520**],[**First Name3 (LF) 718**] W.                   [**Doctor First Name 119**] SICU-A                [**2184-8-11**]  4:01 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 20383**]
 Reason: eval pulmonary fluid status
 Admitting Diagnosis: BACTEREMIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


78 year old woman with CBD transection now trached.


REASON FOR THIS EXAMINATION:


eval pulmonary fluid status
 ______________________________________________________________________________
                                  PFI REPORT
 PFI:  Worsening pulmonary edema.  Increased right, now moderate pleural
 effusion.  Stable left lower lobe collapse and small left pleural effusion.


Neonatology NP Note
Pe
swaddled in open crib, cobedding with twin, AFOF, sutures opposed, respirations unlabored in room air, lungs clear/=, RRR, no murmur,pink and well perfused, face jaundice, abdomen soft, nontender, good tone.


CCU ADMIT NPN
0500:ADDENDUM:  pt. continues to be confused, wanting to get OOB, MS [**Last Name (Titles) 1135**]/wane,  intermittantly less confused.  c/o feeling hot and also c/o rib pain.  T 98.6AX.  HR 114, BP 130/.  diaphoretic.  HO evaluated. given 650mg tylenol and additional 2mg morphine.  pt. appearing more comf., dozing.
HR down to 88SR.  BP 105/54


Subarachnoid hemorrhage (SAH)
   Assessment:
   Action:
   Response:
   Plan:


[**2150-11-2**] 11:27 AM
 SHOULDER [**12-20**] VIEWS NON TRAUMA LEFT                              Clip # [**Clip Number (Radiology) 13947**]
 Reason: evaluate pain
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


65 year old man with hiv,aids and left anterior shoulder pain


REASON FOR THIS EXAMINATION:


evaluate pain
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Left anterior shoulder pain, HIV.

 Three views of left shoulder, with no comparison, show no acute fracture or
 dislocation.  Mild diffuse demineralization is present.  AC joint degenerative
 changes are mild to moderate.

 Lucency is present projecting along the left lateral chest wall on one view.
 Visualized left lung is clear.


IMPRESSION:


1. No fracture or dislocation.  Mild-to-moderate left AC osteoarthritis.
 2. Lucency projecting along left lateral chest wall could represent soft
 tissue emphysema. F/u chest radiographs are recommended.

 The results were discussed with Dr. [**Last Name (STitle) 4601**] at 3:45pm on [**2150-11-2**].


Atrial fibrillation. Left anterior fascicular block. Compared to the previous
tracing of [**2192-10-8**] atrial fibrillation is new.
TRACING #1


NPN Trauma Sicu:
Review of Systems:
Neuro:
ALert, follows simple commands inconsistantly. MAE with rigid movements in all extremities. Given dilaudid and ativan for pain and anxiety.
CV:
Sinus rythum with no ectopy noted. Repleted K+ for level 3.4 BP stable thoughout shift. A-Line lost and no line placed this PM. Sudden large loss of dark red blood from rectum this PM with estimate of 700cc.  HO notifed and in to evaluate. Surgical team notifed, HCT sent off and cross matched for 4 units. No other intervention warrented at this time. Will continue to monitor. Palpable pulses distally.
Respir:
No vent setting changes today. Abg adequate for settings. LSCTA with diminished bases bilaterlly.
GI:
Abdomen large, firm and distended. High pitched sounds auscultated, team aware. As noted above lg episode of blood loss per rectum. Pedi-tube post pyloric with trophic feeds. NGT to cont LWS with bilious drainage.
GU:
Foley to gravity with clear yellow urine, QS.
Social:
Wife in at bedside this afternoon for supportive care.
Plan:
Continue with plan of care.  Monitor HCT, and GI status. Supportive care for pt and family.


[**2140-7-19**] 12:38 PM
 CT ABD W&W/O C; CT PELVIS W&W/O C                               Clip # [**Clip Number (Radiology) 99174**]
 CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION
 Reason: CT UROGRAM DX KIDNEY STONES
 Field of view: 50 Contrast: OPTIRAY Amt: 150
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


52 year old man s/p gastric bypass w/persistent fevers.


REASON FOR THIS EXAMINATION:


CT UROGRAM DX KIDNEY STONES
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Patient is a 52 year old man status post gastric bypass with
 persistent fevers. Evaluate for possible kidney stones.


COMPARISON:


[**2140-5-12**].


TECHNIQUE:


Helically acquired contiguous axial images of the abdomen and
 pelvis were obtained before and after the administration of 150 cc of Optiray
 contrast. Nonionic contrast was used secondary to patient debility. Coronal
 and sagittal reconstructions were obtained.

 CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Within the visualized left
 lung base, there is a 2 mm peripheral nodule present, best seen on series 2
 image 8. In the absence of prior malignancy, a twelve month followup CT is
 recommended to reassess the lesion. There are no other nodules identified
 within the visualized lung bases. There are no pleural effusions. The liver
 gallbladder pancreas spleen and adrenal glands are unremarkable. The patient
 is status post gastric bypass. There is no free fluid and there is no
 mesenteric or retroperitoneal lymphadenopathy. The previously identified 3 mm
 punctate calcific focus within the lower pole of the right kidney is again
 identified, unchanged. The kidneys are otherwise unremarkable, and there is no
 hydronephrosis. It should be noted that the exam was somewhat limited by
 artifact due to the patient's body habitus.

 CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: The distal ureters bladder
 rectum and sigmoid colon are unremarkable. There are coarse calcifications
 within the prostate. There is no free fluid in the abdomen, and no pelvic or
 inguinal lymphadenopathy.

 BONE WINDOWS: Degenerative changes are noted in the thoracolumbar spine. There
 are no suspicious osteolytic or sclerotic lesions.


IMPRESSION:


1. Unchanged 3 mm calculus in the lower pole of the right kidney.
 There is no new nephrolithiasis. 2. Peripheral 2 mm left lower lobe nodule. In
 the absence of known primary malignancy, twelve month CT follow up is
 recommended for further assessment of the lesion.

                                                             (Over)

 [**2140-7-19**] 12:38 PM
 CT ABD W&W/O C; CT PELVIS W&W/O C                               Clip # [**Clip Number (Radiology) 99174**]
 CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION
 Reason: CT UROGRAM DX KIDNEY STONES
 Field of view: 50 Contrast: OPTIRAY Amt: 150
 ______________________________________________________________________________


FINAL REPORT


(Cont)


[**2107-3-5**] 3:21 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 49477**]
 Reason: r/o ptx
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


53 year old man with etoh withdrawl, s/p left subclavian line attempt, please
  asses for pneumothorax


REASON FOR THIS EXAMINATION:


r/o ptx
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Intubated for alcohol withdrawal. Status post left subclavian line
 attempt.

 AP chest, one view: Comparison [**2107-3-2**]. There is an ET tube 3.2 cm above the
 carina. There is a left subclavian line with tip in the SVC. There is no
 pneumothorax. There is an NG tube with tip in the stomach. The lung volumes
 are low. There is atelectasis at the left base. There is no definite
 pneumonia, CHF, or pleural effusion.


NURSING PROGRESS NOTE


2 - FEN - TF=AD LIB FEEDING Q4HRS.  COORDINATED W/ PO
FEEDING. NO SPITS.  ABD SOFT, +BS.  PT [**Name (NI) 215**], [**Name (NI) **].

3 - SOCIAL - NO FAMILY CONTACT THUS FAR TODAY.  SOCIAL WORK
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4939**] IN TO CHECK ON INFANT, AND IS CURRENTLY
TRYING TO CONTACT MOM.

4 - DEV - TEMP STABLE IN OAC.  ALERT, STARTING TO WAKE FOR
FEEDS.  JAUNDICE.  AFOF.


Addendum
mucosal bleeding
   When performing deep epiglottal suctioning, clot noticed coming from
   right side of mouth.
   No blood noticed from trach.
   No blood suctioned from trach.
   MICU team over w/Dr. [**Last Name (STitle) 749**]. Mouth examined with visualization of
   cheeks. ?biting of lower right cheek causing bleeding.
   Will keep on amicar and continue with frequent deep epiglottal
   suctioning.
   Keep monitoring for increasing of any oral bleeding.
   Call MICU team with any changes.
   Assessment:
   Action:
   Response:
   Plan:


Respiratory Care
Baby remains on simv 18 16/5 fio2 ranges from 23-26%.BS clearing after sxning for sm-mod cldy secs.RR 40-60's.No spells documented thus far this shift,she is on caffeine.


PATIENT/TEST INFORMATION:


Indication:


Mitral valve disease. Pericardial effusion.
Height: (in) 60
Weight (lb): 100
BSA (m2): 1.39 m2
BP (mm Hg): 100/40
Status: Inpatient
Date/Time: [**2121-3-5**] at 11:48
Test: Portable TTE(Focused views)
Doppler: No Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


RIGHT VENTRICLE: Right ventricular chamber size is normal.

PERICARDIUM: There is a trivial/physiologic pericardial effusion.

GENERAL COMMENTS: A right pleural effusion is present.

Conclusions:
Left and right ventricular cavity sizes appear normal. There is a
trivial/physiologic pericardial effusion without evidence for hemodynamic
compromise.


Neonatology-NNp Progress Note
PE: [**Known lastname 2627**] remains in her isolette, i on conventional vent 16/4 X14 , bbs sl cse=, rrr s1s 2no murmur, abd soft, nontender, V&S, Picc line in place, under single pt, slightly jaundiced,, generalized edema, afso, active with care

See attending note for plan


0700-[**2034**] PCA Progress Note
i [**Known lastname 4287**] examined baby and have read and agree with the note written by [**First Name8 (NamePattern2) 443**] [**Last Name (NamePattern1) 894**].


[**2152-6-23**] 7:23 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 38926**]
 Reason: Eval. for cardiopulm. abnormality
 Admitting Diagnosis: S/P MOTORCYCLE ACCIDENT
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41 year old man with trauma, just extubated, now diaphoretic and tachycardic.


REASON FOR THIS EXAMINATION:


Eval. for cardiopulm. abnormality
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Trauma, extubated, not diaphoretic and tachycardic.  Evaluate for
 cardiopulmonary abnormality.


COMPARISON:


[**2152-6-20**].

 AP CHEST RADIOGRAPH

 There has been interval removal of the endotracheal tube, right subclavian
 line, and left subclavian line.  Cardiomediastinal hilar contours appear
 unchanged.  No focal consolidation is seen within the lungs.  There are low
 lung volumes limiting complete assessment of the pulmonary vasculature.


IMPRESSION:


No focal consolidations.


[**Last Name (LF) **],[**First Name3 (LF) 734**] A.               OMED 7S                    [**2178-8-26**]  2:23 PM
 PTBD                                                            Clip # [**Clip Number (Radiology) 56411**]
 Reason: PTCA in AM pls
 Admitting Diagnosis: BILIARY OBSTRUCTION
  Contrast: OPTIRAY Amt: 25
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


60 year old man with panc cancer s/p whipple now with bili 26 and likely
  cholangitis


REASON FOR THIS EXAMINATION:


PTCA in AM pls
 ______________________________________________________________________________
                                  PFI REPORT
 Successful placement of a 6.5 French pigtail catheter within the obstructed
 afferent limb via a percutaneous transhepatic approach.  Catheter is connected
 to a bag for external drainage.


Sinus rhythm.  No significant change compared to the prior tracing of [**2192-5-22**].
Probably within normal limits.


[**Last Name (LF) **],[**First Name3 (LF) 815**] R.                   MED MICU                   [**2151-12-30**]  1:33 PM
 BILAT UP EXT VEINS US                                           Clip # [**Clip Number (Radiology) 84820**]
 Reason: ? DVT
 Admitting Diagnosis: FEVER
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


71 year old man with upper extremity swelling, concern for PE


REASON FOR THIS EXAMINATION:


? DVT
 ______________________________________________________________________________
                                  PFI REPORT
 No upper extremity DVT in either arm.  Evidence of right upper extremity AV
 fistula.


TITLE:
   Chief Complaint: Septic Shock/Afib with RVR
   24 Hour Events:
   - urgent renal ultrasound --> did not show signs of obstruction; pt
   does not need IR nephrostomy tubes
   - started empiric flagyl and po vanc for c diff and sent of c diff
   toxin test
   - ECHO:  mild regional left ventricular systolic dysfunction with
   inferior hypokinesis. Trivial mitral regurgitation
   - urine output dropped off significantly for a couple of hours-- he
   responded well to 80mg IV bolus lasix--> about 800ccs urine in first
   few hours, then continued (increased from having very decreased urine
   output)--> started dropping off around 5am; (80 mg IV lasix x 2)
   - given 250cc bolus IVFs to help keep BP, but had crackles in lungs
   - after amiodarone infusion per protocol finished in late evening 1700,
   HR trended up to 130s.  pt had drop in BP w 2.5mg IV metoprolol to MAP
   of 40s-50s, so given 250ml bolus IVFs; HR into 110s, briefly into low
   100s, very labile ; levophed was turned up, vasopressin continued
   - K+ rapidly rising.  At 0200, K+ 5.5 (from 5.4) after 80mg IV lasix
   --> need to watch for continuing rise... so ordered for kayexalate when
   he wakes up;
   will give another 80mg IV lasix if his BP becomes stable and he can
   tolerate
   - Cr and phosphate rapidly rising as well throughout day/night
   - stopped subq Heparin b/c platelets appear to be dropping (dropped
   from 163 to 116 to 90); HIT-Ab sent
   - INR rising as well, but fibrinogen elevated (Acute phase reactant,
   not below 100, so not concerning for DIC); giving 5mg PO vit K when he
   wakes up
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Ciprofloxacin - [**2127-10-21**] 06:09 PM
   Piperacillin/Tazobactam (Zosyn) - [**2127-10-22**] 02:17 AM
   Linezolid - [**2127-10-22**] 08:07 PM
   Metronidazole - [**2127-10-23**] 02:00 AM
   Piperacillin - [**2127-10-23**] 03:00 AM
   Vancomycin - [**2127-10-23**] 05:04 AM
   Infusions:
   Vasopressin - 2.4 units/hour
   Norepinephrine - 0.2 mcg/Kg/min
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2127-10-22**] 08:00 PM
   Omeprazole (Prilosec) - [**2127-10-22**] 08:00 PM
   Furosemide (Lasix) - [**2127-10-22**] 09:30 PM
   Metoprolol - [**2127-10-23**] 01:20 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  [**2127-10-23**] 06:22 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.7
C (101.6
   Tcurrent: 36.6
C (97.9
   HR: 114 (75 - 127) bpm
   BP: 103/53(57) {81/44(51) - 193/167(173)} mmHg
   RR: 29 (17 - 31) insp/min
   SpO2: 96%
   Heart rhythm: AF (Atrial Fibrillation)
   Wgt (current): 81.3 kg (admission): 90.1 kg
    CVP: 9 (6 - 305)mmHg
   Mixed Venous O2% Sat: 75 - 79
   Total In:
                                                                  5,767 mL
                                                                  1,281 mL
   PO:
                                                                     60 mL
                                                                    300 mL
   TF:
   IVF:
                                                                  5,707 mL
                                                                    981 mL
   Blood products:
   Total out:
                                                                  1,370 mL
                                                                    845 mL
   Urine:
                                                                  1,370 mL
                                                                    845 mL
   NG:
   Stool:


[**2159-12-17**] 4:24 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 6736**]
 Reason: r/o PTX/Effusion
 Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


79 year old woman s/p CABG. Please [**First Name8 (NamePattern2) 43**] [**First Name8 (NamePattern2) 6737**] [**Last Name (NamePattern1) 90**] at [**Numeric Identifier 6738**] with
  abnormalities.


REASON FOR THIS EXAMINATION:


r/o PTX/Effusion
 ______________________________________________________________________________
 WET READ: IPf MON [**2159-12-17**] 10:21 PM
  Lines and tube in appropriate placement, with tip of NG tube not identified.
  No acute abnormality.
 ______________________________________________________________________________


FINAL REPORT


AP CHEST, 5:32 P.M. ON [**12-17**]


HISTORY:


Status post CABG.


IMPRESSION:


AP chest compared to [**2159-12-6**]:

 ET tube in standard placement, cuff inflated to the extent that it distends
 with trachea, should be evaluated clinically.  Swan-Ganz catheter ends in the
 right pulmonary artery.  Midline drains and left pleural tube in place.  No
 pneumothorax or pleural effusion.  Hyperinflation due to emphysema better
 demonstrated on the preoperative study.  Normal postop cardiomediastinal
 silhouette.


NPN 1900-0700


1.  RESP:  Pt remains on SIMV 19/5 X33.  FiO3 34-45%.  RR
30-50's.  [**First Name9 (NamePattern2) 63**] [**Doctor Last Name 160**] made aware of increased FiO2 and
increased sat lability this shift.  No new orders obtained.
One desat to 62% with feeds today.  Lung sounds are coarse
to clear.  IC/SC retractions.  She is on caffeine and
vitamin A.

2.  F&N:  TF remain at 150cc/k/d.  PN with IL infusing well
at 110cc/k/d via non-central PICC.  Feeds of BM 20 tol well
at 40cc/k/d.  Abd benign.  BS+.  A/G stable.  No spits
noted.  Scant aspirates noted.  U/O 3.8cc/k/h.  Large mec
stool X1.  Weight gain 19 grams.

4.  PAR:  Mom called for update and [**Doctor Last Name 115**] in to visit X1.
They asked appropriate questions.  [**Doctor Last Name 115**] spoke lovingly to
[**Known lastname 717**].

5.  DEV:  [**Known lastname 717**] is active and alert during her cares.
Temp stable [**Known lastname **] on sheepskin in servo-controlled
isolette.  She puts her hands to her face and sucks on her
pacifier and fingers at times.

6.  C/V:  Soft murmur persists.  HR 150-160's.  She is pink
and well-perfused.  BP 55/44 X47.

7.  BILI:  She remains under single phototherapy.


Initial Nutrition Assessment
   Subjective
   Patient intubated/sedated
   Objective
   Height
   Admit weight
   Daily weight
   Weight change
   BMI
   180 cm
   101.6 kg
   31.3
   Ideal body weight
   % Ideal body weight
   Adjusted weight
   Usual body weight
   % Usual body weight
   78 kg
   130%
   84 kg
   unknown
   %
   Diagnosis: cardiac arrest
   PMHx:
   Bipolar
   Depression
   Alcoholism
   R eye removed in setting of trauma
   Food allergies and intolerances:  none noted
   Pertinent medications: fentanyl drip, cisatracurium besylate,
   ampicillin, heparin, pantoprazole, calcium gluconate repletion,
   magnesium sulfate repletion, LR @ 150 mL/hr, propofol @ 30.3 mL/hr,
   others noted
   Labs:
   Value
   Date
   Glucose
   98 mg/dL
   [**2165-3-25**] 08:28 AM
   Glucose Finger Stick
   106
   [**2165-3-25**] 11:00 AM
   BUN
   37 mg/dL
   [**2165-3-25**] 08:28 AM
   Creatinine
   3.7 mg/dL
   [**2165-3-25**] 08:28 AM
   Sodium
   133 mEq/L
   [**2165-3-25**] 08:28 AM
   Potassium
   4.2 mEq/L
   [**2165-3-25**] 08:28 AM
   Chloride
   99 mEq/L
   [**2165-3-25**] 08:28 AM
   TCO2
   17 mEq/L
   [**2165-3-25**] 08:28 AM
   PO2 (arterial)
   77.[**Numeric Identifier 253**] mm Hg
   [**2165-3-25**] 01:22 PM
   PCO2 (arterial)
   39 mm Hg
   [**2165-3-25**] 01:22 PM
   pH (arterial)
   7.26 units
   [**2165-3-25**] 01:22 PM
   pH (urine)
   5.0 units
   [**2165-3-24**] 09:08 AM
   CO2 (Calc) arterial
   18 mEq/L
   [**2165-3-25**] 01:22 PM
   Calcium non-ionized
   8.4 mg/dL
   [**2165-3-25**] 08:28 AM
   Phosphorus
   4.7 mg/dL
   [**2165-3-25**] 08:28 AM
   Ionized Calcium
   1.07 mmol/L
   [**2165-3-25**] 09:41 AM
   Magnesium
   2.3 mg/dL
   [**2165-3-25**] 08:28 AM
   ALT
   798 IU/L
   [**2165-3-25**] 03:46 AM
   Alkaline Phosphate
   71 IU/L
   [**2165-3-25**] 03:46 AM
   AST
   1520 IU/L
   [**2165-3-25**] 03:46 AM
   Total Bilirubin
   0.6 mg/dL
   [**2165-3-25**] 03:46 AM
   WBC
   13.3 K/uL
   [**2165-3-25**] 03:46 AM
   Hgb
   12.1 g/dL
   [**2165-3-25**] 03:46 AM
   Hematocrit
   36.2 %
   [**2165-3-25**] 03:46 AM
   Current diet order / nutrition support: NPO
   GI: abdomen soft, distended; bowel sounds present
   Assessment of Nutritional Status
   At risk for malnutrition
   Patient at risk due to: NPO status
   Estimated Nutritional Needs
   Calories: 1680- 2100 (BEE x  or /  20-25cal/kg)
   Protein: 85-110 ( 1-1.3 g/kg)
   Fluid: per team
   Calculations based on: adjusted weight
   Estimation of previous intake: likely excessive
   Estimation of current intake: Inadequate
   Specifics: 42 y.o. M found unresponsive at home, EMS called and patient
   noted to be in PEA arrest, taken to [**Hospital3 902**] and transferred to
   [**Hospital1 5**].  Patient started on arctic sun protocol, intubated for
   hypoxic/hypercarbic respiratory failure, now in multisystem organ
   failure.  Possible plan for CVVH.  Nutrition consulted for tube feed
   recommendations. Noted per discussion with RN, currently unable to
   elevated head of bed due to BP issues, also continues with bilious
   output from OGT.  Current propofol drip provides 800 kcal per day, plan
   to stay on [**Name8 (MD) 77**] RN.  Would hold off on tube feeds for now given output
   from OGT and unable to elevate head of bed, however will provide
   recommendations below. Noted repletions.
   Medical Nutrition Therapy Plan - Recommend the Following
          Once OGT output subsides and able to elevate head of bed at
   least 30 degrees to prevent aspiration risk, recommend nutrition
   support via tube feedings.
   1.       Goal tube feed while on propofol is
   2.       Goal tube feed while not on propofol
   3.       Monitor tube feed tolerance with residual checks q4hr, hold if
   greater than 200 mL.
          BG/lyte management as you are.
          Will follow labs/initiation of CVVH and make tube feed
   formula adjustments as needed
          #[**Numeric Identifier 11869**]


Resp Care Note:

Pt cont trached on mech vent as per Carevue. Lung sounds coarse suct sm-th white sput. MDI given as per order. No vent changes made overnoc. Pt had restful noc. Cont mech vent.


[**2200-5-13**] 9:16 AM
 HAND (AP, LAT & OBLIQUE) RIGHT                                  Clip # [**Clip Number (Radiology) 116190**]
 Reason: eval rt hand fx
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


20 year old man with rt hand fx


REASON FOR THIS EXAMINATION:


eval rt hand fx
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Right hip fracture.
 HAND (AP, LAT & OBLIQUE) RIGHT

 Multiple pins are present about the hand as well as hardware related to
 external fixation.  Pins transfix fractures of the proximal middle, ring, and
 small finger metacarpals.  Alignment is overall anatomic and grossly unchanged
 compared with [**2200-4-29**].  No hardware loosening or failure identified.  No
 osteolysis.


Neonatology NP Note
PE
swaddled on open warmer
AFOF,sutures opposed
mild subcostal retractions in room air!!!, lungs clear/=
RRR, no murmur, pink and well perfused
abdomen soft, nontender and nondistended, active bowel sounds
active with good tone
jaundice.

Mom discharged home today, met with parents updated on progress and plan


Mr. [**Known lastname 5934**] is an 88 yo M with CAD s/p CABG, MVR, CHF, COPD, afib, with
   recent admission for chronic L pleural effusion/hemothorax, s/p VATS
   with decortication complicated by HAP, who presents from rehab with
   altered mental status.
   He was admitted to [**Hospital1 1**] from [**Date range (1) 6035**] for evaluation and management
   of L pleural effusion/hemothorax.  He underwent partial decortication
   and parietal pleurectomy on [**4-16**].  His course was complicated by repeat
   mucous plugging requiring bronchosocopy.  He was also treated for CAP
   with levofloxacin and HAP with vanco/zosyn through [**4-30**].  Furthermore,
   he failed multiple swallow evaluations, undergoing a G tube for tube
   feeds.  Hematology evaluated the patient for persistent
   thrombocytopenia, which was felt to be due to MDS.  His INR was also
   persistently high, despite having his coumadin held for his
   procedures.  After a prolonged hospitalization, he was discharged to
   rehab.
   At rehab, his mental status had been below baseline but was slowly
   improving.  However, 24 hrs prior to admission his mental status became
   worse, with more somnolence.  At baseline he is awake and conversant
   according to his son.  The staff also noted an increasing fluid
   collection in his LLE.  Blood work was sent which showed a Hct of 22
   and new leukocytosis.  Also there was a question of bloody stool.  He
   was therefore sent to [**Hospital1 1**] ED for evaluation.
   Since admission, the pt has received a total of 4units PRBCs for HCT as
   low as 20. His MS has greatly improved and he is now A&Ox3. On [**5-8**] he
   was noted to have white out of the left lung on chest xray so thoracic
   [**Doctor First Name **] was consulted. Plan is again discussing option of trach. with
   family vs. supportive care.
   Impaired Skin Integrity
   Assessment:
   Pt with multiple areas of skin breakdown. Skin tear to hematoma site on
   LLE, skin tear to old PICC site on right arm, coccyx reddened and
   perineal area reddened/rashy. Pt also with multiple areas of ecchymosis
   and 2 old chest tube sites to left anterior chest wall.
   Action:
   Mepilex dsgs intact to right arm, and coccyx mepilex dsg changed
   today.  Dsg changed to skin tear over hematoma; xeroform, abd and
   kerlix applied, ortho. in to eval. today. Vaseline gauze, DSD and
   tensoplast applied to old chest tube sites. Aloe vesta barrier cream
   applied to arms/legs. Frequent T/R to keep pt off pressure points.
   Response:
   Pending.
   Plan:
   Cont with current skin care. Cont frequent turning/repositioning.
   Pleural effusion, acute on chronic
   Assessment:
   Pt noted to have near white out of left lung on chest xray [**5-8**], slight
   improvement today. Pt with chronic left sided pleural effusion s/p VATs
   with decortication and pleurectomy [**4-16**]. Chest xrays had since been
   improving until [**5-8**] when significant change was noted. Pt Tachypneic
   into 30s sats 98% on 3L NC, or now on 50% cool neb.
   Action:
   CT of chest today, indicative of mucus plugging. Thoracic [**Doctor First Name **] on
   today, do not feel appropriate to tap at this time.  Pt given chest PT.
   Frequent encouragement to cough/DB. Kept off left side. 50% humidified
   face tent.
   Response:
   Chest xray slightly improved today. Sats remain >93% and pt cont
   Tachypneic. CT with large amounts of mucus plugging/ entire left lung
   collapse. Awaiting family decision about potential trach, although at
   this time it seems as though patient would not want this.
   Plan:
   Plan for supportive care with nebs, humidification, and pul. toilet, or
   trach.  Awaiting family decision r/e trach.
   Additional data:  Picc ordered in attempt to d/c central line.
   ------ Protected Section ------
   Family Meeting:
        Family meeting this evening with Son [**Name (NI) 366**],  patient
s wife, Fellow
   [**Name (NI) **]  [**Name (NI) 6163**], and this RN.  Plan was to discuss goals of care in
   setting of patient with chronically recurring effusion, s/p VATS and
   decortication, and complications related to this.
        Please note on four different occasions today patient indicated to
   this RN that he felt that he may be approaching his time to go to
   heaven.  He indicated that he has had enough of all this, and that he
   is very lonely and bored, and tired of being in the hospital as he has
   been for about a month now.  Patient has been AOx3 today.


Respiratory Care Note:

Pt remain orally intubated on PSV. No vent changes maded during shift. ETT retaped. Pt has mod amt of thick white sputum and copious oral secretions & gaging esp after ETT rotation. Plan: Trach Monday/ Rehab and continue Icu monitoring.


CCU NPN

CV: REMAINS IN NSR WITH HR 65-75. CON'T ON AMIODARONE 400MG. STARTED ON HYDRALAZINE 10 MG FOR SBP 140/ DOSE INCREASED TO 20MG WITH SBP NOW DOWN 125-130. CVP 16-19.

RESP: MECH VENT #7.5 ORAL @ 21L. EQUAL BILAT ANT BS. CURRENT SETTINGS AC 80%,450X14,15. CON'T ON ALB/ATR  SATS 98-100%. SUCTIONED FOR THICK SCANT YELLOW SECRETIONS. BS COURSE/RHONCHI.

GI: TF ON HOLD. HAD ABD PAIN WITH FIRM/DISTENDED ABD OVER LAST 24/HR ABD CT -. OGT TO LIS DRAINING MINIMAL SECRETIONS, BUT ABD SEEMS SOFTER. PT DENIES PAIN. CON'T ON SIMETHICONE. MUSHROOM DRAINING LIQ GOLD STOOL. WILL SEND STOOL FOR C-DIFF IN AM. STOOL IS G +

GU: CON'T TO HAVE HEMATURIA. MANUAL IRRIGATIONS Q 2-4/HR PER UROLOGY. IRRIGATED WITHOUT RESISTENCE. SM -MOD SIZE CLOTTS. URINE IRRIAGTED TILL LIGHT PINK. U/O 45-100CC/HR. LAST CREAT 2.2

SKIN: ALLEVYN TO COCCYX INTACT. R/L GROINS C/D

ID: AFEBRILE. CON'T ON AZTREONAM, VANCO DOSED PER LEVEL QD.

NEURO: FOLLOWS ALL COMMANDS.MAE MOUTHING APPROPRIATLY TO SIMPLE QUESTIONS. VERSED AND FENTANYL FOR SLEEP WITH GOOD EFFECT.

HEME: COMPLETED #1 U PRBC ( HCT 26.1) REPEAT HCT 31.7

LABS; K+ 4.4
      BS 142 NO INSULIN NEEDED PER SS

A/P: CON'T HYPOXEMIA. PULM FOLLOWING. S/P ABD/CHEST CT [**4-10**] SHOWING BILAT EFFUSIONS R>L. WITH ATELECTASIS POSSIBLE PLUGGING. CONM'T TO FOLLOW ABG'S CON'T ABX. SEND STOOL C-DIFF. CON'T PER NSG JUDGEMENT.


74 y.o. male admitted s/p mechanical fall on briefcase with laptop on
   [**5-17**]. Pt went to [**Hospital **] hospital for c/o left flank pain and dizziness. A
   cxr was done which was negative per pt report; no CT was done. Pt
   experienced intermittent abdominal spasms with activity, but by noon on
   [**5-18**], became dizzy and diaphoretic. Pt
s S.O., [**Doctor First Name 2316**], stated he was
   ashen in color. Pt was taken to [**Hospital **] hospital where his initial BP
   was reported 70/palp and his HCT was; and abdominal CT revealed a grade
   4 splenic laceration. He received 2 units of red blood cells and was
   transferred to [**Hospital1 1**] ED. Pt was admitted to T/SICU @ 1800 for Q 4 hour
   HCT checks and hemodynamic monitoring.
   Trauma, s/p
   Assessment:
   Blood pressure and heart rate remain within normal and acceptable range
   without intervention. Pt remains A&O x3. Hourly urine is 30-40cc with
   maintenance IVF infusing at 75cc per hour. SaO2 wnl on room air; LCTA &
   diminished at left base. HCT steady at 23.6(23.9) this am. Minimal
   abdominal & left flank discomfort(spasm) with activity, that pt reports
   [**2146-3-11**] and tolerable; no analgesic therapy necessary.
   Action:
   Am HCT sent
   Orthostatic vitals obtained
   Sips of clears started
   Continuous hemodynamic and urine output monitoring.
   Response:
   Hct 23.4. Trauma team aware- no action at this time.
   Pt tolerated dangling, standing and ambulation activities without
   orthostatic changes.
   Persistent intermittent abdominal spasms with ambulation; pt denies
   need for medication.
   Tolerating 30cc clears per hour. Pt states minimal flatus; + bowel
   sounds; abd softly distended but without change from admission exam.
   Hourly urine output drifting to 28cc then 18cc: IVF increased to 85cc
   per hour. ICU and Trauma teams aware.
   Plan:
   Pt cleared for transfer to floor with telemetry.
   Continue monitoring BP/HR and urine output. Team may consider
   transfusion or fluid bolus.
   Monitor for change in pain assessment and abdominal presentation.
   Continue per transfer orders.
   Demographics
   Attending MD:
   [**Doctor Last Name **] [**Doctor Last Name 407**] J.
   Admit diagnosis:
   SPLENIC RUPTURE
   Code status:
   Full code
   Height:
   Admission weight:
   104 kg
   Daily weight:
   Allergies/Reactions:
   No Known Drug Allergies
   Precautions:
   PMH:
   CV-PMH:
   Additional


history:


glaucoma; arthritis
   Surgery / Procedure and date:
   Latest Vital Signs and I/O
   Non-invasive BP:
   S:154
   D:65
   Temperature:
   99.5
   Arterial BP:
   S:
   D:
   Respiratory rate:
   18 insp/min
   Heart Rate:
   99 bpm
   Heart rhythm:
   SR (Sinus Rhythm)
   O2 delivery device:
   None
   O2 saturation:
   98% %
   O2 flow:
   2 L/min
   FiO2 set:
   24h total in:
   1,457 mL
   24h total out:
   716 mL
   Pertinent Lab Results:
   Sodium:
   140 mEq/L
   [**2145-5-19**] 02:17 AM
   Potassium:
   4.4 mEq/L
   [**2145-5-19**] 02:17 AM
   Chloride:
   111 mEq/L
   [**2145-5-19**] 02:17 AM
   CO2:
   22 mEq/L
   [**2145-5-19**] 02:17 AM
   BUN:
   20 mg/dL
   [**2145-5-19**] 02:17 AM
   Creatinine:
   1.2 mg/dL
   [**2145-5-19**] 02:17 AM
   Glucose:
   137 mg/dL
   [**2145-5-19**] 02:17 AM
   Hematocrit:
   23.4 %
   [**2145-5-19**] 09:48 AM
   Finger Stick Glucose:
   147
   [**2145-5-19**] 02:00 PM
   Valuables / Signature
   Patient valuables:
   Other valuables:
   Clothes:  Sent home with:
   Wallet / Money:
   No money / wallet
   Cash / Credit cards sent home with:
   Jewelry:
   Transferred from: T/[**Hospital 140**]
   Transferred to: CC621
   Date & time of Transfer: [**2145-5-19**] 12:00 AM


PCA Progress Note 0700-1900


#2 FEN:  Total fluids: min 130cc/kg/d of E 24= 60cc q4hrs
all PO.  Pt. took 50-63cc when bottled.  Pt. well
coordinated and eager.  Abd soft and round, +BS, no loops.
Pt. has had no spits.  Pt. is voiding, no stool so far this
shift.  P: Continue on current FEN regimen.

#3 DEV:  Temps stable swaddled and co-bedding with brothers
in [**Name (NI) **].  Pt. is [**Name (NI) **] and active during cares.  Pt. is
waking for all feedings.  Pt. rests well inbetween cares.
MAE. AFSF.  Pt. likes pacifier.  HUS today showed to be
normal.  Pt. passed carseat test.  P: Continue to support
developmental needs.

#4 Parenting: Mom and Grandmother in for 1200.  Mom and
Grandmother very [**Name2 (NI) 967**] with cares and feedings.  Very
involved family.  Updates given by RN at bedside.  P:
Continue to support, update, and educate family.

Please see flowsheet for further details.


Neonatology NP Note
PE
swaddled in open crib
AFOF,
comfortable respirations in room air, lungs clear/=
very soft sytolic murmur at LUSB only, pink and well perfused
abdomen soft, nontender and nondistended, active bowel sounds
active with good tone


HPI:
   Healthy russian speaking 47yF s/p posturing seizure and aspiration at
   home witnessed by fiance; intubated as OSH, loaded with dilantin and
   given 10 decadron. Some L sided weakness. CT with R sided mass
   suspicious for oligodendroglioma s/p crani for right frontal tumor
   resection ([**5-10**])
   [**Last Name **] Problem - [**Name (NI) 10**] Description In Comments s/p crani and removal of
   head mass.
   Assessment:
   Alert and oriented. Moving about in the bed. Sitting up in high fowlers
   position.
   Pupils equal
   Action:
   Response:
   Plan:
   Pain control (acute pain, chronic pain)
   Assessment:
   Pt complaining of headache.. [**3-29**]  speaking Russian, holding head,
   sitting up in the bed. Bp 120syst/
   Action:
   Fiorcet 1 tab po given. Lights out in room.
   Response:
   Pain medication effective after 1hour  Resting comfortably.
   Plan:
   Continue to monitor headache and medicate as per order


[**2181-5-13**] 1:14 PM
 CHEST (PORTABLE AP)                                             Clip # [**0-0-**]
 Reason: ? pna
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


81 year old man with COPD, asthma, SOB, cough


REASON FOR THIS EXAMINATION:


? pna
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


81-year-old man with COPD, asthma, shortness of breath, cough,
 question pneumonia.


FINDINGS:


Portable semi-erect AP radiograph was obtained of the chest.  The
 left lung is clear with no evidence of pneumonia or CHF.  Patchy opacity at
 the right lung base is noted, possibly atelectasis, but infection is not
 excluded.  The heart and mediastinal contour are normal.  No effusion or
 pneumothorax is present.


IMPRESSION:


Right lower lobe patchy opacity, possibly atelectasis, but
 infection is not excluded.
                                                                       DFDdp


NPN 0700-1900


1. RESP
O: Remains in NCO2 100% 25-100cc flow (flow ^ed when held).
Breathing 30-60s, sats 90-97%. Mild baseline SCR noted. LS
clr/=. No spells. A: Stable in current resp support. P: Cont
to monitor for s/s resp distress, wean O2 as tolerated.

2. FEN
O: TF 150cc/kg/day of BM26/PE26 + PM. Gavaging 46cc over
1hr, 10 mins. Put to breast @ 1230, did not latch but
rooted; will schedule mom for another consult. [**Month (only) 24**] introduce
bottle tonight. Abd exam benign. A/G 27cm. No spits, min
asps. Voiding and stooling (Heme-). On FeSO4. O: Tolerating
feeds. P: Cont to monitor FEN status, monitor for s/s
feeding intolerance, begin POs as interested.

3. G&D
O: [**Known lastname 626**] is [**Known lastname **]/active with cares. Temps stable swaddled.
Cobedding w/twin. [**Last Name (LF) 33**],[**First Name3 (LF) 120**]. Roots and brings hands to face.
Likes belly. Eyes to be followed in 3 wks. A: AGA. P: Cont
to provide dev appropriate care.

4. [**First Name3 (LF) **]
O: Mom in for 1230 & 1630 cares. Attempted to BF [**Known lastname 626**],
needs much instruction and support. Mom had consult this
[**Last Name (LF) 448**], [**First Name3 (LF) 43**] schedule another for end of week or next week.
Mom is sl.weepy today as Dad left to return to [**Hospital1 346**]
last night. Will return tomorrow @ 1230 for bath [**Last Name (un) 26**]. A:
Attentive, loving family. P: Cont to support and educate
family.

See flowsheet for details.


[**2128-7-28**] 6:54 AM
 NEONATAL HEAD PORTABLE                                          Clip # [**Clip Number (Radiology) 20467**]
 Reason: one month follow up
 Admitting Diagnosis: NEWBORN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


Infant born at 28 weeks now one month old


REASON FOR THIS EXAMINATION:


one month follow up
 ______________________________________________________________________________


FINAL REPORT


HEAD ULTRASOUND:


HISTORY:


Premature infant, born at 28 weeks gestation.  Now one month of age.
 Evaluate for PVL.

 CRANIAL ULTRASOUND:  Comparison is made with the previous head ultrasound
 dated [**2128-7-2**].

 Since the previous study there has been appropriate interval maturation of the
 brain.  The cerebral and cerebellar architecture are within normal limits.
 The ventricles are normal in size and there is no evidence of intraventricular
 or intraparenchymal hemorrhage.  The extra-axial fluid spaces are normal.


IMPRESSION:


Normal cranial ultrasound.


[**2162-4-4**] 3:06 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 24593**]
 Reason: eval for acute process
 Admitting Diagnosis: CELLULITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


80 year old woman with hypertensive urgency


REASON FOR THIS EXAMINATION:


eval for acute process
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


80-year-old female with hypertensive urgency.


COMPARISON:


[**2162-2-6**].


TECHNIQUE:


Axial CT images through the head were acquired without intravenous
 contrast.


FINDINGS:


There is no evidence of hemorrhage, large mass, mass effect, edema,
 or hydrocephalus.  There is preservation of [**Doctor Last Name 107**]-white matter differentiation.
 The basal cisterns appear patent.  Prominent ventricles and sulci suggest
 age-related involutional changes.  White matter hypodensity suggests sequela
 of chronic small vessel ischemic disease.  There is an old lacunar infarction
 in the right caudate head, unchanged since the prior study. There is no
 evidence of recent infarction.

 Complete opacification of the right sphenoid sinus is again noted.  Hyperdense
 vitrea of the right globe is again seen, unchanged since the prior study.
 Arterial calcifications are again noted. Again seen is opacification of the
 sphenoid sinus with a thickened, sclerotic wall, indicating chronic
 inflammation.


IMPRESSION:


No evidence of hemorrhage or infarction. Numerous chronic
 abnormalities described above.


pmicu npn 7p-11p

   pt requested and received 2mg ivp dilauded q3hrs w/modest relief of incisional pain. he was also pancultured for temp 101.5 orally.


[**2146-4-10**] 6:08 PM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY                          Clip # [**0-0-**]
 Reason: CHEST PAIN, TACHYCARDIA, ? PULMONARY EMBOLUS
  Contrast: OPTIRAY Amt: 100
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


82 year old man with history of pleuritic type chest pain, tachycardic.


REASON FOR THIS EXAMINATION:


Evaluate for pulmonary embolus.
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: SHfd SUN [**2146-4-10**] 9:19 PM
  RML and left segmental PE. right lower lobe pna or lymphangitic cspread of ca,
  multiple pulm  nodules-masses.
 ______________________________________________________________________________


FINAL REPORT


REASON FOR EXAM:


History of metastatic bladder cancer.  Chest pain.  Clinical
 concern for pulmonary embolism.


COMPARISON:


Chest radiograph from earlier the same day and chest radiograph
 from [**2146-1-12**].


TECHNIQUE:


Multidetector CT images of the chest before and after
 administration of IV contrast as per routine pulmonary embolism protocol with
 coronal and sagittal reformats were submitted for interpretation.

 NON-CONTRAST CHEST CT:  Thyroid gland appears unremarkable.  There is no
 intramural hematoma.  Calcified pleural plaques compatible with asbestos
 disease of the pleura are noted.  Atherosclerotic calcifications of the
 coronary arteries and aortic valve are mild-to-moderate.

 POST-CONTRAST CHEST CT:  There is complete occlusion of the right middle lobe
 pulmonary artery, compatible with acute pulmonary embolism. Wedge shaped
 peripheral opacity in the right middle lobe, is most likely pulmonary infarct.
 There is also a filling defect within the posterior subsegmental branches of
 the left upper lobe (3:28).  The aorta demonstrates atherosclerotic
 calcifications.  There is no aortic dissection.  The heart is not enlarged.
 There is no pericardial effusion.  There is no mediastinal, hilar, or axillary
 lymphadenopathy by size criteria.  A few subcentimeter mediastinal lymph nodes
 measuring up to 7 mm in the right paratracheal region are identified.  There
 is also a 9-mm subcarinal lymph node.  There is a small right pleural
 effusion.  There are multiple pulmonary nodules throughout both lungs.
 Partially imaged upper abdominal organs are grossly unremarkable.  The
 gallbladder is partially imaged and distended.

 OSSEOUS STRUCTURES:  Old right-sided posterior rib fractures are noted within
 the lower ribs.  There is no osseous lesion to suggest malignancy or
 infection.


IMPRESSION:


1.  Right middle lobe segmental pulmonary embolism and corresponding wedge
 shaped peripheral opacity, most likely pulmonary infarct.  Also noted is a
 left posterior upper lobe subsegmental pulmonary embolism.
                                                             (Over)

 [**2146-4-10**] 6:08 PM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY                          Clip # [**0-0-**]
 Reason: CHEST PAIN, TACHYCARDIA, ? PULMONARY EMBOLUS
  Contrast: OPTIRAY Amt: 100
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 2.  Multiple pulmonary nodules compatible with metastatic disease.
 3.  Evidence of asbestos disease of the pleura.


NPN 0700-1900


FEN: Received infant on TF 150cc/kg/day BM/[**Doctor Last Name **] 24. TF decr'd
today to TF [**Doctor Last Name 145**] 130cc/kg/day. Needs 42cc Q4hrs. Bottled 55
and 50cc Q4hrs thus far this shift. TFI for 24hrs 168cc/kg/
day. All PO's. Coordination improving w/playtex bottle. Abd
exam is benign. +BS. Tol feedings well. No spits. Voiding qs
and stooled x2. P: Continue to monitor and support FEN.

G&D: Maintaining stable temps in OAC. A&A w/ her cares and
sleeping well bwtn. Brings hands to face to comfort self;
sucks on hands and loves her binki. Waking for some feeds on
her own. desitin applied to bottom for minimal amt redness.
AFSF. MAEW. AGA. P:Continue to promote optimal G&D.

A's and B's: No Apnea and bradycardia noted since 0400 last
shift. Thus infant now Day 0/5 of brady countdown and all
PO's. Occ brady at rest; more frequent bradys w/ feedings,
refer to flowsheet. P: Continue to monitor for A's/B's.

[**Doctor Last Name 2**]: Please refer to NPN for [**Known lastname 2212**] Triplet #1.

See flowsheet for further details.


NPN 7A-7P:

NEURO: A/OX2. SHE HAS THE PESSIMER VALVE IN. SHEIS ABLE TO MAKE HER NEEDS KNOWN. SHE IS ABLE TO MAE. AT TIMES SHE C/O RIGHT SHOULDER PAIN.

CV: NSR W/ PVC/PAC NOTED. TEMP MAX 98.8.

RESP: THE PT IS A CHRONIC TRACH. LS CLEAR, AND DIMINSHED BILAT. O2 SAT 100% ON 35% MIST. WEAK COUGH. RN ENCOURAGED COUGHING AND DEEP BREATHING. SHE DID REQUIST TO BE SUCTIONED X 4. SPUTUM YELLOW AND THICK. SHE IS ABLE TO USE THE YAUNKER INDEP.

GI/GI: CL DIET TOL WELL. SHE IS ABLE TO TAKE HER MEDS CRUSHED. + BS NO STOOL. FOLEY CATH WAS LEAKING URINE. 10 CC PLACED IN BALLOON. GOOD UA OUT PUT.

SKIN: INTACT.

LABS: HCT 25.6

POC: QUESTION BLOOD TX.


NPN


#1
Infant remains in N/C 100%; 13-25cc tonight maintaining sats
mid/high 90s.  Occasional quick drifts in sats to low 90s
that SR.  Bs clear= with mild retractions(increased with po
feeding).  Continues on Diurel and KCL as ordered.  Color is
[** 211**]; murmer not audible.

#4
Infant continues on [** **] 130cc/k of E26 and is bottling ~q4
hours. He took in 129cc/k over the past 24 hours.  Infant
has taken 70-75cc with each feeding thus far tonight.  He
does well for ~first half and then needs encouragement to
continue.  Small spits x2 while burping.  And is soft and
round; voiding; no stool noted.  Wt is up 20gms-3360.

#5
Infant remains in an open crib with a stable temp.  Infant
is [** **] with cares; slowly waking for feeds after ~4 hours
tonight.  Sleeps well between cares.

#6
No contact thus far tonight from mom.


Clinical Nutrition
O:
39 wk gestational age BB, LGA, now on DOL 3.
Birth wt: 3810 g (>90th %Ile); current wt: 3610 g (-65g)(down ~5% from birthwt)
HC:  33.5 cm (~50th %Ile)
LN:  49.5 cm (~50th to 75th %Ile)
Labs noted
Nutrition:  100 cc/kg/day TF.  NPO.  IVF D10 w/ lytes via PIV; plan to start PN today.  Projected intake for next 24hrs from PN ~46 kcal/kg/day, ~3 g pro/kg/day; no lipids.  GIR from PN ~7 mg/kg/min.
GI: ABdomen benign; good bowel sounds.  Passing meconium.

A/Goals:
Tolerating IVF w/ good BS control.  Plan to start PN tonight.  Remains NPO for now due to respiratory status under O2 [**Doctor Last Name 744**].  Labs noted and PN adjusted accordingly.  INitial goal for PN is ~70 to 80 kcal/kg/day, ~3 to 3.5 g pro/kg/day, and ~3 g fat/kg/day.  Holding lipids at this time in order to maximize protein on fluid allowance due to LGA.  PN will be advanced as per protocol and tolerance as fluid limit allows.  Also may be constrained by PIV access.  Expect infant to start pg feeds soon; initial goal is ~165 cc/kg/day BM/E 20, providing ~110 kcal/kg/day and ~1.7 to 2.3 g pro/kg/day. Expect PN to taper as EN advances towards initial goal.   Further increases in feeds as per growth and tolerance.  Growth goals after initial diuresis are ~20 to 35 g/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain.   WIll follow w/ team and participate in nutrition plans.


Hypertension, benign
   Assessment:
   Action:
   Response:
   Plan:
   Wound infection
   Assessment:
   Action:
   Response:
   Plan:
   Respiratory failure, acute (not ARDS/[**Doctor Last Name **])
   Assessment:
   Action:
   Response:
   Plan:


[**2150-5-8**] 11:19 AM
 C-SPINE NON-TRAUMA [**1-22**] VIEWS                                    Clip # [**Clip Number (Radiology) 21664**]
 Reason: C/O NECK PAIN  R/O DJD NECK PAIN
 ______________________________________________________________________________


FINAL REPORT


INDICATIONS:  60-year-old woman with complaint of neck pain.

 CERVICAL SPINE, AP AND LATERAL:  There are no prior studies available for
 comparison.  The cervical spine is visualized through T1 on the lateral view.
 There is no evidence of a fracture, dislocation, or bony destruction.
 Equivocal minimal anterolisthesis of C7 on T1 is observed, although the
 appearance may relate to patient position.  There are intervertebral disc
 space narrowings from C4-C5 through C6-C7, most pronounced at C5-C6, with
 anterior osteophytes.  There is also slight probable loss of intervertebral
 body height from C3 through C6, without wedging. There is no prevertebral soft
 tissue swelling. Sternal wires are observed in the inferior edges of these
 views.


IMPRESSION:


Degenerative changes of the cervical spine as described.


Chief Complaint:  s/p seizure, withdrawal
   HPI:
   HPI: Mr. [**Known lastname 5525**] is a 47 yo M with h/o seizure d/o, EtOH abuse who
   presents after suffering seizure at work.  He states that he was in his
   usual state of health until today at work when he was sitting at his
   desk when he lost conciousness.  When he awoke he felt fatigued and EMS
   was around him.  He states this was like his previous seizures, for
   which he states he gets 1/mo.  He was therefore taken to the ED.  Of
   note, he states that he has had a sz disorder since [**12**] and has been a
   verying doses of dilantin, which he reports being adherent to.  He
   denies any focal neurological symptoms, new medications/supplements, or
   recreational drugs other than EtOH.  He admits to different amounts of
   EtOH to different people.  To me he admitted to 1 case beer /wk, last


Respiratory Care Note
Pt received on PSV as noted. BS clear bilaterally. Pt suctioned for small amt thick, bloody secretions. ETT repositioned and retaped w/o incident. Pt changed to heated circuit. Pt taken to CT Scan for head - results pending. Plan to remain on current settings at this time.


ADMISSION: 37M s/p fall of [**2073**] feet, now with etoh withdrawal,
   thrombocytopenia, nondisplaced T9 and L1 fx, R montaggio fx
   CURRENT ISSUES:
   EtOH withdrawal
   Pancytopenia
   Non Displaced T9 and L1 fractures
   R Montaggio fx
   Sepsis (gram position cocci)
   Hyponatremia (SIADH)
   Trauma, s/p fall off ladder 12-15ft
   Assessment:
   Pt intubated and weaned to PSV, TV >1L, adequate minute ventilation,
   able to wake and follow all commands, strong cough leak
   Action:
   Pt extubated placed on face tent, strong productive cough
   Response:
   Pt with extreme tremors when extubated, settled with Ativan 5mg, sats
   98% on 35% humidified face tent, able to cough secretions with
   encouragement
   Plan:
   Continue CIWA scale, encourage coughing and deep breathing, monitoring
   closely
   .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)
   Assessment:
   Pt with strong tremors when extubated, extensive history of ETOH abuse,
   alcohol toxicity
   Action:
   CIWA scale
   Response:
   Pt resting comfortably once medicated with Ativan
   Plan:
   Continue CIWA scale
   Sepsis without organ dysfunction
   Assessment:
   Action:
   Response:
   Plan:


Chief Complaint:
   24 Hour Events:
   --changed to fentanyl gtt to reduce rebound agitation following boluses
   --large mucus plug suctioned from trach
   --hypotensive to 80's at 0230, stopped fentanyl and midazolam, gave 1L
   bolus
   Allergies:
   Penicillins
   Rash; blisters;
   Tetracycline
   Rash;
   Sulfa (Sulfonamides)
   Rash;
   Last dose of Antibiotics:
   Vancomycin - [**2169-4-2**] 11:52 AM
   Cefipime - [**2169-4-3**] 06:07 AM
   Infusions:
   Fentanyl - 25 mcg/hour
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2169-4-2**] 04:09 PM
   Famotidine (Pepcid) - [**2169-4-2**] 08:00 PM
   Midazolam (Versed) - [**2169-4-3**] 12:30 AM
   Fentanyl - [**2169-4-3**] 03:29 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  [**2169-4-3**] 06:12 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since [**71**] AM
   Tmax: 37.7
C (99.9
   Tcurrent: 37.6
C (99.7
   HR: 72 (64 - 86) bpm
   BP: 93/42(54) {74/39(48) - 136/58(74)} mmHg
   RR: 14 (14 - 25) insp/min
   SpO2: 100%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 72.2 kg (admission): 80.8 kg
             Total In:
                                                                  4,006 mL
                                                                  1,765 mL
   PO:
             TF:
                                                                    508 mL
   IVF:
                                                                  3,128 mL
                                                                  1,765 mL
   Blood products:
   Total out:
                                                                  1,516 mL
                                                                    483 mL
   Urine:
                                                                  1,516 mL
                                                                    483 mL
   NG:
   Stool:


Neonatology
Increaseed number of apnea noted over previous hours. PAtient remains well appearing. No mrumur. Abdomen benign. Well perfused activity normal. Scroitum normal in appearance currentyl. Testes normal bilaterally. Blueness improved over that reported by Dr [**First Name (STitle) **] at her exam yesterday afternoon as reoported in signout.

Moderate amount of oropharyngeal secretions noted. Has responded to NP tube changes over past 24 h, but continued secreations and spells. On abx after sepsis eval last night. BC remains negative.

Will intubate and monitor response in spells. Furrthereval/rx as dictated by this repsonse.

Team to contact family.


[**Last Name (LF) **],[**First Name3 (LF) 16594**] P.            TSURG TSICU                [**2169-4-28**]  5:42 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 59542**]
 Reason: ? interval change
 Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


66 year old man s/p vats


REASON FOR THIS EXAMINATION:


? interval change
 ______________________________________________________________________________
                                  PFI REPORT
 No change.


[**2110-8-24**] 5:00 AM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 43473**]
 Reason: s/p iv lasix evaluate failure
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


86 year old woman elevated BNP with chf, h/o pericardial window


REASON FOR THIS EXAMINATION:


s/p iv lasix evaluate failure
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Elevated BP and CHF with history of pericardial window.


COMPARISON:


[**2110-7-15**].


FINDINGS:


PA and lateral chest radiograph reviewed.  There are small/moderate
 bilateral pleural effusions.  A right pleural effusion is loculated with fluid
 present in both the minor and major fissures.  There is some left retrocardiac
 atelectasis.  There is cardiomegaly and the heart is enlarged from the
 interval.  The mediastinal contours are stable. The thoracic aorta is
 tortuous.


IMPRESSION:


1.  Bilateral pleural effusions as described.
 2.  Enlarged heart, pericardial effusion in addition to cardiomegaly cannot be
 excluded.
 2.  Thoracic spine compression fractures, unchanged.


MICU/SICU NPN HD #12
S: "Can I have some juice?"

O:

Neuro: pt is A&Ox2-3, occasionally verbally inappropriate, reporting abdominal pain but unable to quantify, MAEW

Resp: LS coarse, dim at bases, SpO2 88-96% on 50% cool neb, coughing and expectorating amall amts thick tan/rust secretions

CV: AVSS, please see flowsheet for data

Skin: C/W/D/I

GI/GU: abd soft, NT/ND, BS present, tolerating sips of liquids without difficulty, Foley patent for clear yellow urine in adequate amts

Lines: right radial art line day # 4, left brachial PICC day #3

A:

altered breathing r/t increased resp secretions
activity intolerance r/t gerneral deconditioned status, increased O2 requirement
risk for injury r/t activity intolerance, general deconditioned state
pain, acute on chronic r/t metastatic disease

P:

contniue to monitor hemodynamic./respiratory status, contniue aggressive pulmonary toilet, continue to wean O2 as tolerated, activity progression as tolerated, ADAT


[**2187-7-31**] 11:54 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 58087**]
 Reason: Please eval for aspiration
 Admitting Diagnosis: PERIPHERAL VASCULAR DISEASE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


68 year old man who swallowed pills and now c/o SOB,course breath sounds,
  and with decreased sats


REASON FOR THIS EXAMINATION:


Please eval for aspiration
 ______________________________________________________________________________


FINAL REPORT


CHEST SINGLE AP FILM:


HISTORY:


Shortness of breath, coarse breath sounds and decreased oxygen
 saturation.

 Allowing for technique, heart size is within normal limits.  No definite CHF.
 There are small bilateral pleural effusions.  Since the prior film of [**7-28**], [**2186**], there is more confluent opacity in the left lower zone with
 obscuration of the slightly elevated left hemidiaphragm, as well as
 ill-defined opacity at the right lung base that is new since the prior film.
 No pneumothorax.


IMPRESSION:


Bibasilar opacities consistent with atelectases/consolidation
 slightly worse at both bases since the prior film of [**2187-7-28**].
 Persistent small bilateral pleural effusions.


[**2158-9-12**] 10:27 AM
 VIDEO OROPHARYNGEAL SWALLOW                                     Clip # [**Clip Number (Radiology) 72849**]
 Reason: pt failed several bedside swallow studies; video requested b
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


59 year old woman with failed bedside swallow studies; speech/swallow requested
  video study.


REASON FOR THIS EXAMINATION:


pt failed several bedside swallow studies; video requested by swallow team
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


59 y/o woman with swallowing difficulties, failed bedside swallow
 study.


FINDINGS:


This study was performed in conjunction with the speech therapist.
 Various consistencies of barium were administered orally.  There was frank
 aspiration of the nectar thick barium.  Oral residue was seen with all
 consistencies which cleared spontaneously.  The patient demonstrated reduced
 chewing.  There was a prominent cricopharyngeus impression with retrograde
 flow from the PES to the pharynx.


IMPRESSION:


Frank aspiration with the nectar thick barium.


Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway
   Clearance, Cough)
   Assessment:
   Easy gag and cough reflex, pt agitated when moved in bed.  Hypertension
   occurs with activity
   Action:
   HOB > 30, Ativan 2mg/2hrs for aggitation, Fentanyl gtt for pain
   Response:
   Patient appears to be resting comfortably.  SBP 100-120
s, Reports no
   pain with non-verbal cues
   Plan:
   Continue to administer Ativan and Fentanyl per orders
   Candidiasis, Oral
   Assessment:
   Candidiasis observed in buccal cavity
   Action:
   Mouth care with chlorhexadine and nystatin applied
   Response:
   Candidiasis remains
   Plan:
   Continue with aggrassive mouth care and nystatin
   Pain control (acute pain, chronic pain)
   Assessment:
   Change in vital signs with movement and repositioning as well as
   grimacing.  Patient will respond to question of pain with non-verbal
   cues (hand squeeze) pain present
   Action:
   Fentanyl gtt running, repositioning for comfort
   Response:
   Patient appears to be resting comfortably
   Plan:
   Continue to monitor for change in vitals, continue with gtt and med
   bolus
s PRN


MICU-NPN

NEURO: PT. remains sedated on Fentanyl and ativan gtt.
CV: afebrile, HR 79-93 SR with occ. PVC's, ABP 94-117/47-99, Pitressin decreased to 0.02U/min with SBP stable in the low 100's and MAP >60. Will con't to wean as tolerated.
RESP: LS coarse with occasional exp. wheezes. vent settings remain the same except PEEP was increased on prior shift with slight improvement in ABG's, see carevue for data. Suctioned for small/mod. amt's of thick, yellow sputum.
GI: abd. soft and distended, hypo BS, small amt. of stool output via colostomy. Stoma large and pink. TPN infusing, NGT to LWIS with biliuos drng. Abdominal incision continues to drain mod. amt's of sero sang drng. Exudry dsg to absorb drng.
GU: u/o 25-40cc/hr.


NPN 11p-7a


#2 [**Known lastname 867**] has remained in rm air with SaO2 > 94. had one
desat to 66 while sleeping QSR. LS clear and equal but
stridorous especially when bottling. mild subcostal
retractions. A: occ desats P: monitor
#3 cont in open crib with temp stable. waking occ for feeds,
poor suck and little interest in pacifier, fairly calm with
cares, sleeps well between feeds. A: [**Known lastname 168**] with some dev
issues P: cont to support.
#4 [**Known lastname 867**] has no feed tube and po's poorly, using [**Last Name (un) **]
feeder he took 40 & 30 cc BM 26 this shift. total po intake
yesterday 80cc/k/d. weight gain only 10 grams yesterday. Abd
benign, soft, +BS, no loops or distention noted. vdg qs, no
stool.  A: poor po feeder P: cont to feed as able.


Sinus bradycardia. Diffuse low voltage. Prior inferior wall myocardial
infarction. Left bundle-branch block. Compared to the previous tracing
of [**2182-5-1**] sinus rhythm has appeared.


[**2189-1-21**] 2:43 AM
 CT C-SPINE W/O CONTRAST                                         Clip # [**Clip Number (Radiology) 101303**]
 Reason: eval for fx
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


46 year old man found down


REASON FOR THIS EXAMINATION:


eval for fx
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: ACKe WED [**2189-1-21**] 3:47 AM
  no fractures
  c4-5 fusion
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


46-year-old man found down.

 NONCONTRAST CERVICAL SPINE CT WITH CORONAL AND SAGITTAL REFORMATTED SCANS:

 There is anterior cervical spine fusion seen at C4-C5.  Degenerative changes
 are seen at this level and at C3-4 and C4-5, as well as moderate to severe
 spinal stenosis. No fractures are identified.  There is mild kyphosis at C3-4
 probably related to degenerative changes and fusion. The patient is intubated
 and has a nasogastric tube; prevertebral soft tissue swelling cannot be
 assessed. There appears to be some posterior pleural thickening at the right
 pulmonary apex.


IMPRESSION:


Degenerative changes of the spine, spinal stenosis, with cervical
 spine fusion at C4-5; no acute fracture is identified.


TSICU
   HPI:
   88yoF s/p fall ~0330 [**9-14**], neg LOC, unable to get up, found by son
   ~1900 and transported from scene.
   Injuries:
   L prox humerus frx, L dis rad/ulna frx
   unstable C5&6 frx, L facial lac
   Chief complaint:
   post op C [**5-25**] decompression and fusion, remains intubated
   PMHx:
   PMH: htn.
   PSH: unknown
   [**Last Name (un) **]: atenolol & asa
   Soc:  unknown
   Current medications:
   1000 mL LR 4. 500 mL LR 5. Acetaminophen 6. Atenolol 7. CefazoLIN 8.
   Chlorhexidine Gluconate 0.12% Oral Rinse
   9. Docusate Sodium 10. Famotidine 11. Fentanyl Citrate 12. Insulin 13.
   Magnesium Sulfate 14. Ondansetron
   15. Pneumococcal Vac Polyvalent 16. Senna 17. Sodium Chloride 0.9%
   Flush 18. Sodium Chloride 0.9% Flush
   24 Hour Events:
 INVASIVE VENTILATION - START [**2140-9-15**] 09:19 PM
 ARTERIAL LINE - START [**2140-9-15**] 09:47 PM
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Cefazolin - [**2140-9-16**] 04:00 AM
   Infusions:
   Propofol - 20 mcg/Kg/min
   Other ICU medications:
   Other medications:
   Flowsheet Data as of  [**2140-9-16**] 04:41 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**43**] a.m.
   Tmax: 36.4
C (97.5
   T current: 36.4
C (97.5
   HR: 76 (71 - 95) bpm
   BP: 116/49(73) {112/49(73) - 149/63(96)} mmHg
   RR: 14 (14 - 14) insp/min
   SPO2: 99%
   Heart rhythm: SR (Sinus Rhythm)
             Total In:
                                                                  3,884 mL
                                                                    942 mL
   PO:
             Tube feeding:
   IV Fluid:
                                                                  2,634 mL
                                                                    942 mL
   Blood products:
                                                                  1,250 mL
   Total out:
                                                                    635 mL
                                                                    143 mL
   Urine:
                                                                     85 mL
                                                                    143 mL
   NG:
   Stool:


[**2129-8-17**] 2:36 PM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 58732**]
 Reason: ? Worsening pulmonary edema in setting of CHF exacerbation v
 Admitting Diagnosis: CONGESTIVE HEART FAILURE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


76 year old woman with CHF exacerbation, SOB and lower extremity edema.


REASON FOR THIS EXAMINATION:


? Worsening pulmonary edema in setting of CHF exacerbation vs. consolidation
 ______________________________________________________________________________


FINAL REPORT


CHEST, TWO VIEWS


INDICATION:


76-year-old woman with CHF.

 COMMENTS:  PA and lateral radiographs of the chest are reviewed, and compared
 with previous study of [**2129-8-13**].

 There is prominence of the pulmonary vasculature with cardiomegaly indicating
 mild congestive heart failure.  The pacemaker leads remain in place.  No
 pneumothorax is seen.


IMPRESSION:


Mild congestive heart failure with cardiomegaly.


0700-1500 NPN


SEPSIS: Continues on Ampicillin and Gentamicin x48hr r/o
sepsis. VS stable per flowsheet, no evidence of sepsis at
this time.

RESP: Currently in RA with RR 30s-50s, 02 saturation 95-99%.
LS clear/=, no retractions noted. No bradys or desats at
this time.

FEN: Received NPO on TF 60cc/kg/d D10w infusing via PIV.
Infant is currently ordered to po ad lib demand and IVFs are
to be weaned as tolerated. Infant was put to breast once and
offered bottle twice thus far but has not shown interest in
po feeding as of yet. IVF infusion rate has been decreased
to 30cc/kg/d; plan to check follow-up dstick within 4hrs of
change in IVF rate. Abdomen soft, round, no loops, active
BS. Voiding small amounts, no stool.

DEV: Received on servo control warmer. Warmer shut off this
a.m. and infant dressed and swaddled at that time. Temp is
currently stable. MAE, fontanels soft and flat. Occasionally
awake with cares but has been sleepy throughout most of the
morning. Sucks on pacifier for comfort. AGA.

PARENTING: Parents visited this a.m. and took turns holding
infant. Mom attempted to breastfeed however infant was
sleepy and not interested at the time. RN provided update
and support.


Respiratory Care
Baby currently on cpap 5, fio2 27-30%, bs clear, sx mod-large cloudy secretions, cpap decreased from 6, on caffeine and diuril, no spells on this shft thus far. Will continue to follow.


assessment as noted in carevue

res: remains on t/collar, strong prod/congested cough, helped with sputum clearence by suctioning-sm amnt thick white, ls clear, maintains sat>98

cv: stable bp, on lopressor , +weak pulses, no edema, all line are intact/patent


neuro: alert, follows commands, lifts r.arm well, l.arm and legs are weak, nods to questions, denies pain

renal: creat and bin are up, is for HD today

skin: abd wound red/intact, dsg was changed, allevin on coccyx, stoma is benign

heme: hct 28

gi: tol tf well at goal, passing liq brown stool via ileostomy, +bs, soft/distended abd

id: WBC up to [**Numeric Identifier 1102**], cont on vanco and zosyn

social: daughter called last night and was udated on pt condition

plan: monitor res, hct, id, HD today, start working on sending pt back to rehab


Admission Date:  [**2121-8-7**]              Discharge Date:   [**2121-8-14**]

Date of Birth:  [**2083-6-15**]             Sex:   F

Service: MEDICINE

Allergies:
Ketorolac / Aspirin

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
tylenol overdose

Major Surgical or Invasive


Procedure:


endotracheal intubation

History of Present Illness:
MS. [**Known lastname **] is a 38 YOF with history of refractory depression,
prior suicide attempts who was brought to OSH ([**Hospital1 46**] Hx) after
ingestion of "large amount of tylenol." Pt called husband at
12:30 today and told him she took Tylenol and Seroquel last
night. Husband called the police/EMS who found her in her bed at
home at 1250; pt able to walk out of the house, very combative.
She told EMS she took Seroquel and Tylenol last night and more
Seroquel today of unknown amount. Pt became incoherent and
uncooperative in ambulance. On arrival to OSH at 13:30, VS were
98.9, 91, 127/86, 26, 100% on NRB. Pt had rotatory nystagmus and
dilated pupils, unresponsive. Nl ekg. Pt intubated at 13:45 with
Etonidate 20, succinylcholine 120, Ativan 1mg, and sedated on
propofol gtt. NAC was started at 14:30 following this protocol:
NAC 7.5 over 1 hr, 2.5 over 4 hrs, 5 over 16 hrs. AST 698, ALT
348, INR 0.99, bili nl at 2pm. TCA 43 (nl 50-200), Tylenol 349
([**11-15**]), benzos pos (>200). Nl CXR, nl head CT. She was given
Ativan 2 mg at 1520, another 1 mg Ativan and vecuronium 10 mg at
16:00 for sedation. She also received 2 L NS.

Upon arrival to [**Hospital1 **] ED: VS were Tmax 100.4 HR 80  BP 140/87  RR
18 100% on vent settings, which were A/C Vt 480, RR 12, PEEP 5,
FiO2 50%. Propofol was initially at 9.9 cc/hr (20 mg/kg), then
increased to 13.2 cc/hr (40 mg/kg) in the ED. OGT placed. NAC
continued at 125 cc/hr (50 mg/kg). CXR confirmed correct ET tube
placement. Toxicology and Liver were consulted.

On arrival to the MICU, VS were 98.9, 88, 144/76, 100% on vent
settings A/C: 0.5 480x12 5 7.41/32/430, leading to PIP 14, Plat
P 10. Pt overbreathing vent at rr 17. [**Name (NI) 1094**] husband reports pt
took 1.5 bottles of Tylenol, unknown amounts of Seroquel and
possibly trazodone, Adderall, and morphine SR.


Past Medical


History:


Fibromyalgia
Seizure Disorder (no formal diagnosis from a neurologist)
Depression/anxiety
HTN
Recent pancreatitis


Social


History:


Social


History:


Married. Lives in [**Location 18825**]. On disability for
fibromyalgia.


Family


History:


Family


History:


Mother passed away two years ago from Pancreatic
CA. Father with HTN, gallstones.

Physical


Exam:


MICU ADMISSON


EXAM:


General: young woman, lying in bed, awake, alert, NAD
HEENT: sclerae anicteric, PERRLA, no JVD
Cor: regular rate and rhythm, normal S1 and S2, no M/R/G
Pulm: clear to auscultation bilaterally
Abd: +BS, soft, nontender, mildly distended
Extrem: warm, 2+ pulses, capillary refill intact; no edema
Skin: no rash, petechiae, ecchymoses; no breakages in skin
Neuro: AAO x 3, CN II-XII intact, strength and sensation grossly
normal bilaterally. Speech fluent.
.
FLOOR TRANSFER


EXAM:


General: young woman, sleeping
HEENT: sclerae anicteric, PERRLA, no JVD
Cor: regular rate and rhythm, normal S1 and S2, no M/R/G
Pulm: clear to auscultation bilaterally
Abd: +BS, soft, nontender, mildly distended
Extrem: warm, 2+ pulses, capillary refill intact; no edema
Skin: no rash, petechiae, ecchymoses; no breakages in skin
Neuro: AAO x 3, Motor and Sensation grossly intact.  Speech
fluent.

DISCHARGE


EXAM:


General: young woman, NAD
HEENT: sclerae anicteric, MMM.
Cor: regular rate and rhythm, II/IV RSB systolic flow murmur.
Pulm: clear to auscultation bilaterally
Abd: +BS, soft, tender over RUQ, LUQ.
Extrem: warm, no edema, or cyanosis
Skin: no rash, petechiae, ecchymoses; no breakages in skin
Neuro: AAO x 3, strength and sensation grossly normal
bilaterally.


Pertinent Results:
Admission Exam Labs:
[**2121-8-7**] 08:52PM   GLUCOSE-129* UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-2.9* CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
[**2121-8-7**] 08:52PM   ALT(SGPT)-667* AST(SGOT)-1244* LD(LDH)-1103*
ALK PHOS-118* AMYLASE-331* TOT BILI-1.0
[**2121-8-7**] 08:52PM   LIPASE-30
[**2121-8-7**] 08:52PM   ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-4.2
MAGNESIUM-2.1
[**2121-8-7**] 08:52PM   ACETMNPHN-144*
[**2121-8-7**] 08:52PM   WBC-10.4 RBC-4.02* HGB-12.8 HCT-38.2 MCV-95
MCH-31.9 MCHC-33.5 RDW-14.3
[**2121-8-7**] 08:52PM   PT-14.8* PTT-27.7 INR(PT)-1.3*
[**2121-8-7**] 05:50PM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2121-8-7**] 05:50PM   ASA-NEG ETHANOL-NEG ACETMNPHN-186*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG

Discharge Exam Labs:
[**2121-8-14**] 05:40AM BLOOD ALT-694* AST-72* AlkPhos-92 TotBili-0.5
[**2121-8-14**] 05:40AM BLOOD PT-11.4 PTT-26.8 INR(PT)-0.9
[**2121-8-14**] 05:40AM BLOOD WBC-3.4* RBC-3.23* Hgb-10.5* Hct-30.5*
MCV-95 MCH-32.4* MCHC-34.3 RDW-15.2 Plt Ct-256
[**2121-8-13**] 05:50AM BLOOD Lipase-18

Brief Hospital Course:
38yo F w/ significant psychiatric history, including numerous
suicide attempts, s/p Tylenol and polysubstance overdose
presented with AMS, elevated LFTs, and Tylenol level of 350.
.
# Hepatotoxicity from Tylenol Overdose: Based on history
reported by pt's husband, Ms. [**Known lastname **] most likely overdosed on
Tylenol and other psychiatric medications.  Her LFT's peaked at
AST 6132 ALT 3862, and her INR peaked at 1.9.  She is expected
to regain full recovery of her liver function.  She was HIV and
Hepatitis B and C negative. Her LFTs should be rechecked at her
first outpatient primary care follow-up.
.
# Polysubstance abuse/overdose: She admitted overdosing with
tylenol and other psychiatric medications.  She may have other
ingestion's as well.  Her tox screen was positive for benzos.
Her TCA level was in the therapeutic range.
.
# Suicidal Ideation and H/o significant psychiatric illness: Pt
seems to have a significant psych burden with positive family
history and previous history of numerous suicide attempts. She
had no suicidial ideation or plan when she was admitted to the
floor.  Per pt's husband's report, pt has severe social anxiety
disorder, treatment-resistant depression, and ADHD.  All of her
psych medications were held due to leukopenia.
.
# Unclear HCP: Currently pt's husband is official HCP, but this
was decided and documented ~5 yrs ago. Now the husband is no
longer living with the pt; he moved out recently.
.
#Nausea: She complained of nausea when she arrived on the floor
from the MICU.  She was given Zofran PO and her nausea resolved.
She was able to tolerate a diet.
.
#Leukopenia:  Once of the floor her white blood cell count
continued to decrease.  Her ANC nadired on [**2121-8-13**] at 500.
Her white blood cell count is now trending up. Her CBC should be
checked at her first outpatient PCP's appointment or if she has
a fever or any symptoms of infection.
.
#Abdominal Pain: The patient intially complained of upper
quadrant abdominal pain.  However, with IVF's and PO morphine
her pain has decreased.  Her diet has been advanced to a regular
diet.

Medications on Admission:
Ativan 1 mg QAM, 2 mg QHS
Tylenol 650 mg Q6H
Morphine SR 15 mg Q8H prn
Methylphenidate 20 mg TID
Duloxetine DR 60 mg QD
Seroquel 300 QHS
Zofran 4 mg Q8H prn pain
Gabapentin 800 mg TID
Additional meds found at home:
Cymbalta 60 mg QD
Provigal 200 mg QD
Allergies: ketorolac and aspirin

Medications on Transfer:
Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO/NG QID:PRN
heartburn
Lisinopril 10 mg PO/NG DAILY
Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation View
Docusate Sodium 100 mg PO DAILY:PRN constipation
Lorazepam 1 mg IV Q6H:PRN Anxiety
Morphine Sulfate 2-4 mg IV Q4H:PRN pain
Pantoprazole 40 mg IV Q12H

Discharge Medications:

1. Morphine 15 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
3. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**1-18**] Tablet, Rapid
Dissolves PO every eight (8) hours.
4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
every six (6) hours as needed for constipation.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Miralax 17 gram Powder in Packet Sig: Seventeen (17) G PO
once a day as needed for constipation.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as
needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
9. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
10. Aluminum-Magnesium Hydroxide 300-150 mg Tablet, Chewable
Sig: One (1) Tablet, Chewable PO four times a day as needed for
heartburn.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnosis:
Tylenol Overdose

Secondary Diagnosis:
Depression with suicide attempt


Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.


Discharge Instructions:
Dear Ms. [**Known lastname **],

Thank you for receiving your care at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] Hospital.  You
were admitted for a Tylenol overdose.  Your are expected to make
a full recovery, and your liver function continues to improve.
You have been medically cleared to seek treatment for your
suicide attempt, or tylenol overdose.
The following medications were changed:
Zofran 8 mg Q8H prn pain

The following medications were stopped:
Ativan 1 mg QAM, 2 mg QHS
Tylenol 650 mg Q6H
Methylphenidate 20 mg TID
Duloxetine DR 60 mg QD
Seroquel 300 QHS

The following medications were added:
Lorazepam
Milk of Magnesia
Pantoprazole
Miralax
Senna
Docusate
Bisacodyl
Tums


Followup Instructions:
Please follow up with your Psychiatrist.  When you are
discharged from the psychiatric unit you will need to see a PCP
[**Name Initial (PRE) 176**] 1 week to check your liver function tests and CBC.



Completed by:[**2121-8-17**]


Shift Summary
Pulmonary edema post extubation today, s/p exploratory lap w/ lysis of adhesions day 4.
N: A&Ox3 post extubation, vocalzing without difficulty. dc'd propofol 1600hr. Generalized weakness, strong and equal finger grasp bilateral. PERRLA.
CV: Soft sys murmur. CK's negative x3. R IJ TLC transduced w/ CVP 2 post diuresis, lasix this am. Labetolol drip for SBP>180 this AM weaned @1800hr w/ SBP 130-140. Medial and distal ports w/ good blood return flushed and capped. R AC double lumen PICC flushed and capped. R a-line w/ sharp wave form correlating w/ cuff. No edema, SCD's bilaterally. Telemetry in NSR w/out ectopy throughout the day HR 70-80bpm
R: Extubated 1630 to 40% FM. Large blood plug sx'd from pharyngeal area most propable r/t cont nose bleed. Post extubation bilateral coarse upper lobes instructed on C&DB, weak cough requires oral sx'ing. Sats>95% per puse ox.
GI: Abd remains firmly distended unchanged throughout the day w/ BS +x4. Wife states pt had one loose stool approximately 1 wk ago. No BM noted. Staples intact with several firm hematomas along suture line, MD aware. Wound w/out drainage well approximated. Fentanyl 50mcgs given 1600 for c/o continues abd pain. Wife states pt requires interventional IV pain management to combat increased anxiety r/t pain. R nares NGT to low intermittent sx 150cc green bile secretions x12hrs.
GU: UOP approximately 200cc/hr w/ Lasix 40mg IVP x1 this AM. L FA AV graft w/ +bruit/thrill. s/p kidney transplant year [**2187**],no HD ?recent complications r/t possible rejection may require future PD vs HD per renal attending.
Skin: Intact. Abd wound as above
ID: Remains afebrile througout the day. Pre extubation suctioning reveals bloody clear secretions.
Plan: Encourage C&DB, pending post extubation ABG results.cautious NT suctioning d/t continued nose bleed. TPN restarted this PM. FSG 99-113 prior to TPN, continue to monitor bedside glucose. Support pain management w/ IV Fentanyl assessing pain level frequently. Possible thoracentesis tomorrow r/t RLL plueral effusion.


81M with history of HOCM, CHB s/p pacer, DM, recent complicated
   enterococcal bacteremia currently on ampicillin, presenting with
   episode of unresponsiveness, hypoglycemia, and hypothermia.  Found
   unresponsive at [**Hospital1 169**] this AM and glucose found to be in 50s.  EMS called
   and IO placed.  Given 1 amp D50 which brought glucose up to 80s.
   Briefly bagged (x4 minutes) in the field due to poor mental status.
   .
   Edema, peripheral
   Assessment:
   Worsened peripheral edema as per report,much more on the L than R,trace
   edema on upper extremities,LENI neg for DVT,known HOCM,
   Action:
   Response:
   Edema remains as stated above,urine output 50-60cc/hr,
   Plan:
   Cont to monitor edema,  I
s and O
s, BP
   Hypoglycemia
   Assessment:
   BS at MN was 54,completely asymptamatic
   Action:
   Received 1amp d50.
   Response:
   F 124 after the d50,
   Plan:
   Cont to monitor BS q 6 hours. encourage PO intake.


[**2181-1-9**] 4:09 PM
 CHEST (PRE-OP PA & LAT)                                         Clip # [**Clip Number (Radiology) 48313**]
 Reason: removal sternal wires
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


43 year old woman with prominent sternal


REASON FOR THIS EXAMINATION:


removal sternal wires
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


43-year-old female with prominent sternal wires, awaiting removal
 of sternal wires.


FINDINGS:


Comparison is made to a prior radiograph from [**2180-6-13**].

 The heart size and mediastinal contours are stable. The pulmonary vascularity
 is normal. There is evidence of improved bilateral lower lobe opacity, as well
 as interval resolution of a left upper lobe opacity. There is minor residual
 atelectasis at the lung bases bilaterally, as well as a minimal amount of
 atelectasis in the left midlung zone. There is some blunting of the
 costophrenic angles bilaterally suggesting pleural thickening or pleural
 effusions. These are improved when compared to the previous exam. There are no
 new areas of parenchymal consolidation or pulmonary nodules. There is evidence
 of prior midline sternotomy. There are seven sternal wires which are
 visualized in the lateral view. These sternal wires are intact. There is
 diffuse osteopenia and mild kyphosis of the thoracic spine.


IMPRESSION:


Improved bilateral patchy opacifications within the bilateral lung
 bases and the left midlung zone. Some residual atelectasis within the left
 midlung zone and the lung bases bilaterally. Small bilateral pleural
 effusions. Seven intact sternal wires in place.


80yo Portugese speaking female S/P recent hospitalization at [**Hospital1 3633**] with
   CP -> cath lab where she was found to have 3VD (including 95% LM): No
   intervention and surgery declined her as she was too high risk. She was
   DC
d to home and suffered a  reoccurrence of chest pain 2 days later ->
   ruled in at [**Hospital3 2794**] for STEMI ( Inferior MI). Peak cpk 1350.
   Transferred to [**Hospital1 19**] for re-evalulation of CABG.  Pt admitted on
   heparin and ntg, NTG weaned off [**7-29**], remains on heparin. Cardiac
   Surgery came by to see pt and now have cardiac cath films from [**Hospital1 3633**] as
   of [**7-30**]; CSurg waiting to determine her candidacy is c/b ARF and HCV
   cirrhosis.
   Temp pacing wire inserted [**7-30**] for bradycardia 28-30 Afib s/p inferior
   MI.
   [**8-2**]; pacer rate increased and patent started both IV Lasix gtt and
   diuril as having increasing O2 requirements (on non-rebreather) and
   worsening edema.
    Has experienced some confusion over past few days but cooperative w/
   care. Alert and oriented x [**2-16**].  Supportive dtrs have been staying with
   patient overnight given confusion and language barrier.
   Renal failure, acute (Acute renal failure, ARF)
   Assessment:
   Urine output low this am, with urine dark amber colored. AM CR/BUN 2.3
   and 81. Minimal increase in urine output to dopamine gtt and Lasix
   bolus given prior shift. Patient appears more fluid overloaded with
   crackles in bilateral bases as well as 4 + LE edema, most notable in
   thighs.  Patient also with increasing O2 requirement from NC; received
   patient on non-rebreather mask with sats mid-90
s. patient positive 10
   liters since admission.
   Action:
   ABG obtained at start of shift while patient on non-rebreather.
   Dopamine gtt at 5 mcg/kgmin throughout the day. Initiated Lasix gtt at
   5 mg/hr as well as started [**Hospital1 7**] chlorthiazide. Encouraged repositioning
   and elevation of patient extremities to help with edema. Evening renal
   / electrolyte labs sent. Daily weight. Renal team is following patient
   progress. Monitored respiratory status/lung exam and edema.
   Response:
   ABG 7.40/27/64; maintained on non-rebreather and attempted aggressive
   diuresis with increasing doses of Lasix gtt (now at 15 mg/hr) as well
   as diuril. Currently patient is negative approximately 200 cc
   Dopamine gtt now at 10 mcg/kg/min. Weight today 65 kg (up from 55.5 kg
   at admission). Starting at 1730 attempting weaning from non-rebreather;
   Currently maintained sats > 92% with combination of 6 L NC with 100%
   FiO2 face tent. Labs pending.  Lung exam improved over the course of
   the day, now bases diminished and upper lobes clear. Edema with only
   marginal improvement.
   Plan:
   Continue IV Lasix with [**Hospital1 7**] diuril. Closely monitor I/O, daily weights.
   Await results pending labs. Renal/CCU team discussing potential for
   CVVH intiation with family should medical diuresis fail (heparin off in
   event patient needs dialysis line placement).
   Atrial fibrillation (Afib)
   Assessment:
   Patient in afib rate 40s-70
s with frequent VPaced beats at start of
   the shift (VVi rate at 40) on dopamine gtt. Temporary pacing wire
   maintained in right IJ. Heparin gtt therapeutic at 400 units/hour.
   Action:
   Monitored temp wire settings and site. Hemodynamic monitoring. CCU team
   with EP discussed potential TEE/CV- heparin dc
d for potential of this
   procedure. No antiarrhythmic medications at this time.
   Response:
   Temp wire rate increased to 80 by EP fellow instead of TEE/CV as (per
   report) patient unlikely to remain in SR if successfully cardioverted
   as no antiarrythmic medications are recommended at this time, as well
   as patient would likely require intubation for the TEE/CV. Patient now
   mostly VPaced at 80 with periods of intrinsic AFib rhythm also some
   PAC
s this afternoon. Temporary pacer dressing changed, site now dry
   and intact.
   Plan:
   Continue to monitor temp wire site and management of settings. Also
   titrate dopamine gtt as tolerated goal MAP 50-60.  No plan at this time
   for TEE/CV although heparin remains off for potential CVVH line
   placement.
   Urinary tract infection (UTI)
   Assessment:
   Patient with UTI. Patient also with some confusion per family members,
   patient is unclear where she is and the date, but knows who she is and
   all her family members. Remains pleasant. Today with vomiting
   immediately after taking oral antibiotic. Afebrile, am WBC 8.6.
   Action:
   Obtained order for IV abx as patient vomited oral. Encouraged po intake
   and cranberry juice. Re-oriented by family prn.
   Response:
   Patient afebrile. Patient continues with poor appetite, nutrition
   recommending boost to be delivered on tray with meals.
   Plan:
   Continue to encourage nutritional status-? Tube feeding/ NG tube for
   po/ng meds.  Continue to support patient orientation prn with family
   members.


Seizure, without status epilepticus
   Assessment:
   pt alert and oriented. Perl
   no c/o pain
   swallowing pills with [**Last Name **] problem.
   Action:
   ativan 1.5mg ivp q6hrs atc given as ordered.
   continuous eeg in place.
   Response:
   no obvious seizures seen.
   dilantin level 23
   Plan:
   cont. to monitor for seizures and notified neuromed of changes.


S:"I'm in pain, I take lots of pain medicine at home for the past 4 years for back pain."

O: please see careview for full detail.

CV:av paced with underlying NSR. HR70 BP 107/56.one pneumoboot in place r/t past DVT in right leg.

RESP: pt extubated today placed on cool aerosol tent mask with good o2sats 98%. LS clear diminished at bases bilat.

GU:draing clear yellow urin via foley.

GI: pt was able to drink some water while taking his pills without difficulty. +BS -BM.

neuro: pt alert oriented x3. c/o pain 2mg hydromorphone worked well for pain in back. pt does not want to lean on right side r/t pain in that area.

endo: insulin gtt off pt will start on ss insulin.

skin: lower back hemovac intact. elastoplast covering original surgical dsg. pts hip dressing oozed blood when he was turned side to side. dressing was changed clean dry intact.

a:pain

P:keep pt pain free, move pt slowly to prevent more pain. [**Last Name (un) 11539**] diet per orders. monitor blood glucose.


Admission Date:  [**2134-8-8**]              Discharge Date:   [**2134-8-10**]


Service: [**Hospital Unit Name 196**]

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Syncopal episode with complete heart block

Major Surgical or Invasive


Procedure:


DDD Pacer on [**2134-8-9**]


History of Present Illness:
The patient is an 86 year old female with a history of left
bundle branch block, hypertension, bladder cancer s/p
tranurethral resection on [**2-14**], multiple syncopal episodes,
clean cath at [**Hospital1 112**] on [**2132-7-29**] who presented to the ER at [**Location (un) **]
via EMS after she was found on [**2134-8-9**] by a neighbor after she
collapsed in her backyard. The patient had been gardening and
lifting heavy boulders when she suddenly lost consciousness and
collapsed to the ground. She experienced some midepigastric
abdominal pain upon awakening, no nausea or vomiting, no chest
pain, shortness of breath, or diaphoresis. She did feel
lightheaded and dizzy. She began to have agonal respirations and
EMS found her to be in complete heart block with only a palpable
blood pressure and minimally responsive. She was intubated on
the field and given atropine 1.0 mg and versed 5 mg IV. Her
blood sugar was 132. She was externally paced by EMS at 70 at
normal sinus rhythm. Upon arrival at [**Location (un) **], the patient
received dopamine and was placed on the ventilator. Her CK-MB
was 2.8, with an index of 12.3, CPK 227, and troponin was less
than 0.2. An interal pacing wire was placed and then transferred
to the [**Hospital1 69**]. Upon arrival at
[**Hospital1 18**], her BP was 101/42 and was in normal sinus rhythm. Her
CK-MB was 7 with a troponin of less than 0.1. Her EKG showed
LBBB with 2-[**Street Address(2) 2051**] elevations in v1 and v2 that did not meet
ischemic criteria. Her chest xray showed minimal bilateral
pleural effusions and she was given Lasix 20 mg once. Her clean
cardiac catheterization at [**Hospital1 112**] in [**2132**] was indicated secondary
to an abnormal stress echo. She had a history of multiple
syncopal episodes, her last being in [**3-17**], to which she
attributed to what she believed was hypoglycemia.

Past Medical


History:


HTN
Osteoporosis
Hyperthyroidism s/p thyroidectomy
h/o MVA with multiple rib fractures
bladder cancer s/p transurethral resection in [**2-14**]
cholelithiasis s/p cholecystectomy
appendectomy
bilateral femoral inguinal hernias s/p bilateral repair


Social


History:


The patient lives alone and does not smoke nor drink alcohol.
She is retired and is a widow of 20 years.

Family


History:


Significant family history for a mother who died at the age of
55 with a heart attack.

Physical


Exam:


Pulse 47, Sinus bradycardia    BP 102/41   Vent AC 500/96/12/5

General - intubated and sedated
HEENT - Pupils equally responsive to light, +2 carotid pulses
bilaterally with no bruits
Heart - 8-10 cm JVD, clear S1 and S2 with a mild grade II/VI SEM
heard best at the left lower sternal border, radiating to the
axilla
Lungs - Clear to auscultation with mechanical breath sounds and
bibasilar crackles
Abdomen - Nontender, nondistended, with active bowel sounds
Extremities - No cyanosis, clubbing, or edema with +1 dorsalis
pedis and posterior tibial pulses bilaterally


Pertinent Results:
[**2134-8-8**] 10:30PM   PO2-403* PCO2-43 PH-7.38 TOTAL CO2-26 BASE
XS-0
[**2134-8-8**] 10:30PM   LACTATE-1.2
[**2134-8-8**] 10:30PM   freeCa-1.10*
[**2134-8-8**] 08:30PM   GLUCOSE-126* UREA N-21* CREAT-1.1 SODIUM-142
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2134-8-8**] 08:30PM   CK-MB-7 cTropnT-<0.01
[**2134-8-8**] 08:30PM   WBC-11.6* RBC-4.03* HGB-12.3 HCT-35.7* MCV-89
MCH-30.6 MCHC-34.5 RDW-13.4
[**2134-8-8**] 08:30PM   NEUTS-74* BANDS-8* LYMPHS-11* MONOS-5 EOS-0
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2134-8-8**] 08:30PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-1+
[**2134-8-8**] 08:30PM   PLT COUNT-223
[**2134-8-8**] 08:30PM   PT-12.4 PTT-22.2 INR(PT)-1.0

Brief Hospital Course:
The patient was transferred to the CCU where she remained
intubated overnight and placed on CPAP with PSV of [**4-16**] in the
morning.

1. Cardiac
Rhythm: She remained in sinus bradycardia and her beta blocker
which she took at home was discontinued so as not to slow her
atrioventricular node conduction. EP was consulted and
repositioned her internal pacing wire after it was seen on CXR
to be in her inferior vena cava. A repeat CXR after
repositioning confirmed correct placement in the right atrium
and she was placed on Cefazolin 1 gm IV Q8 for the periprocedure
period with plans for DDD pacer placement on [**2134-8-9**]. She
tolerated the procedure well without complications.

Pump: Due to minimal volume overload on physical exam, Lasix 20
mg IV x 1 was administered. She was continued on an ACE-I and
scheduled for an echocardiogram to assess overall cardiac
function and rule out any wall motion abnormalities.

Coronary Artery Disease: She was continued on [**Date Range **]. At the time,
there is no reason to believe she has CAD given her clean cath
in 02.

2. Gastrointestinal
Elevated liver function tests were noted on admission. The plan
included a right upper quadrant ultrasound to assess the liver,
presumably in shock liver after decreased forward flow following
her complete heart block episode. Hepatitis serologies were
taken and are pending. As she was discharged from the hospital
before a right upper quadrant ultrasound could be obtained and
her immediate cardiac issues seem to resolve and her LFTs were
decreasing, it was recommended tha the patient follow up with
her PCP as soon as possible to assess any liver abnormalities.

3. Musculoskeletal - osteoporosis
The patient was continued on fosamax once a week.

4. Pulmonary - respiratory failure
The patient remained intubated overnight at 500/12/5 and weaned
off the vent in the morning and was extubated on [**2134-8-9**].

She was then transfered to the telemetry floor after her DDD
pacer placement on [**2134-8-9**] and remained in sinus rhythm. She was
discharged on [**2134-8-10**] in good condition and in normal sinus
rhythm.

Medications on Admission:
Lisinopril 30 mg PO QD, Atenolol 50 mg PO QD, Omeprazole 20 mg
PO QD, Chlothalid 25 mg PO QD, Quinine 260 mg PO QD, Fosamax 70
mg PO [**Last Name (LF) 55956**], [**First Name3 (LF) **] 81 mg PO QD, Prilosec 20 mg PO QD

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO once a
week.
3. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).


Discharge Disposition:
Home With Service

Facility:
[**Hospital6 **]

Discharge Diagnosis:
Complete heart block, pacer implanted


Discharge Condition:
Good.

Discharge Instructions:
Please return to the ER or call your primary care physician if
you experience any chest pain, shortness of breath,
lightheadedness, or dizziness.

Followup Instructions:
Please follow up with your electrophysiologist Dr. [**Last Name (STitle) **] in
1 month by calling 1-[**Telephone/Fax (1) 285**].
Provider:  [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2134-8-17**] 9:00
Please follow up with your primary care physician.


[**2170-6-4**] 7:13 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 81434**]
 Reason: r/o new infiltrates,  worsening chf
 Admitting Diagnosis: ENDOCARDITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


69 year old man with endocarditis   w/ inc resp rate, new oxygen requirement


REASON FOR THIS EXAMINATION:


r/o new infiltrates,  worsening chf
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


69-year-old with endocarditis.  Worsening CHF.  New oxygen
 requirement.


TECHNIQUE:


Portable AP chest radiograph.


COMPARISON:


Chest radiograph dated [**2170-6-2**].


FINDINGS:


The patient is status post CABG with median sternotomy.  Cardiac
 pacemaker leads are unchanged compared to the prior study.  Again note is made
 of cardiomegaly.  Thoracic aorta is tortuous.  There is new left lower lobe
 consolidation with effusion, which may represent pneumonia.  There is
 increased interstitial markings with vascular markings, representing worsening
 failure.


IMPRESSION:


Cardiomegaly and worsening congestive heart failure.  New left
 lower lobe consolidation, which may represent pneumonia.  Please correlate
 clinically.

 Dr.  [**Last Name (STitle) 5932**] has been informed.


NPN 0700-1900


#2Resp:  Pt. remains on prong CPAP 6, FiO2 21%.  RR 40-70's,
sats > 89%.  No spells or desats so far this shift.  Lungs
clear & equal w/ mild IC/SCR.  P: cont to monitor resp
status.

#3FEN: Currently, TF @ 140cc/kg/d of D15 1:2 infusing well
through DL UVC.  D-sticks have been unstable this shift.
Plan to hang PND13 @ 100c/kg & ?D12.5 @ 40cc/kg this
afternoon.  D-sticks today have been 47/52/141/176/61.  Plan
to check D/s at 1730. Last D10W bolus given at 7am.  Pt.
remains NPO.  Abd full & soft  w/ soft loops.  OGT to vent.
Pt. has had 2.4cc of bilious asp so far this shift.  AG
stable.  Urine output for 12hrs is 4.7cc/kg/hr.  No stool so
far this shift.  Stool ordered to be sent for tox screen.
P: follow d-sticks closely & check lytes in am.

#4DEV:  Temps stable nested in sheepskin in servo isolette.
Pt. active & irritable w/ cares.  Settles well in between.
Likes pacifier.  MAE.  AFSF.  P: cont to support dev needs.
State screen to be drawn in am.

#5Parenting:  Mom in throughout the day.  Mom participating
in cares.  Asking [** **] questions.  Updates given.  Family
mtg held.  P: cont to support & update.

#6Hyperbili:  Pt. continues under neoblue.  Pt. ruddy, well
perfused.  Eye shields in place.  Rec faxed to check cord
blood for type & coombs.  P: check bili in am.
See flowsheet for further details.


Sinus rhythm. Biatrial enlargement. Occasional ventricular ectopy. Compared to
the previous tracing of [**2197-5-25**] there is variation in precordial lead
placement. The rate has slowed. Otherwise, no change.


Nursing PRogress Note


#1/#8 O: cont on nasal prong cpap 6cms 21% FiO2; lungs
clear/equal, color pale [** 211**]/mottles w/cares. RR 30's-60's
w/baseline mild sc/ic retractions. Caffeine as ordered, no
apnea or bradycardia episodes noted this shift. nares
suctioned for lg amt cloudy secretions w/blood tinge, not
yellow, howerver. Receiving Gentamycin/Vancomycin as
ordered. Bactroban to nares as ordered. Nasal swab + for
staph aureus. A: nares irritated from prongs but otherwise
nicely stable on cpap. P: trial of npcpap to rest nares,
meds as ordered.
#3 O: TF 140cc/k/d SC 30 w/PM, on pump over 90 mins for hx
spitting. no spits or asp today, abd benign, vdg and passing
sm amts brown guiac neg stools. vitE/Ferinsol as ordered. A:
stable on feeds as above P: cont per present care.
#4 O: dad called this morning and updated on babies. mom is
home sick w/bad cold so family won't be visiting for a few
more days. A: loving family P: cont to update and support.
transfer babies to [**Hospital3 71**] when stable.
#5 O: temp stable swaddled in off isolette. pacifier w/cares
to settle. will have repeat HUS on [**12-3**] to assess evolving
germinal matrix bleed. [**Month/Day (4) 4**] need update on US from [**11-19**].
A: AGA P: cont to assess and support developmentally. follow
hus.


Chief Complaint: resp failure/arf/ards
   I saw and examined the patient, and was physically present with the ICU
   Resident for key portions of the services provided.  I agree with his /
   her note above, including assessment and plan.
   HPI:
   24 Hour Events:
 MIDLINE - STOP [**2112-5-24**] 03:00 PM
 PICC LINE - START [**2112-5-24**] 03:00 PM
   Rheum c/s
   Esoph balloon placed--peep maintained at 16
   History obtained from ho
   Patient unable to provide


history:


intubated
   Allergies:
   Cipro (Oral) (Ciprofloxacin Hcl)
   Hives;
   Cardura (Oral) (Doxazosin Mesylate)
   urinary inconti
   Codeine
   Nausea/Vomiting
   Bactrim Ds (Oral) (Sulfamethoxazole/Trimethoprim)
   Nausea/Vomiting
   Augmentin (Oral) (Amox Tr/Potassium Clavulanate)
   Nausea/Vomiting
   Last dose of Antibiotics:
   Azithromycin - [**2112-5-24**] 08:00 AM
   Cefipime - [**2112-5-24**] 08:36 PM
   Vancomycin - [**2112-5-25**] 09:21 AM
   Infusions:
   Fentanyl - 125 mcg/hour
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2112-5-25**] 08:51 AM
   Midazolam (Versed) - [**2112-5-25**] 08:51 AM
   Other medications:
   reviewed
   Changes to medical and family


history:


PMH, SH, FH and ROS are unchanged from Admission except where noted
   above and below
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2112-5-25**] 10:23 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.9
C (100.2
   Tcurrent: 37.9
C (100.2
   HR: 84 (62 - 90) bpm
   BP: 149/59(90) {123/45(73) - 163/107(119)} mmHg
   RR: 15 (14 - 21) insp/min
   SpO2: 98%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 60 Inch
             Total In:
                                                                  1,186 mL
                                                                    875 mL
   PO:
             TF:
                                                                    636 mL
                                                                    305 mL
   IVF:
                                                                    550 mL
                                                                    510 mL
   Blood products:
   Total out:
                                                                  1,129 mL
                                                                    310 mL
   Urine:
                                                                  1,129 mL
                                                                    310 mL
   NG:
   Stool:


[**2145-4-28**] 7:00 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 66174**]
 Reason: Evaluate for pneumothorax
 Admitting Diagnosis: CHEST PAIN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


62 year old man s/p ICD placement via axillary,


REASON FOR THIS EXAMINATION:


Evaluate for pneumothorax
 ______________________________________________________________________________
 WET READ: PABl WED [**2145-4-28**] 10:29 PM
  New ICD placement with leads in appropriate position. No Pneumothorax. Left
  sided pleural effusion.
 ______________________________________________________________________________


FINAL REPORT


CHEST RADIOGRAPH


INDICATION:


Followup.


COMPARISON:


[**2145-4-25**].

 In the interval, a pacemaker has been inserted.  The generator is in
 unremarkable left pectoral position.  The course of the leads is unremarkable.
 There is no evidence of pneumothorax.  Otherwise, there are no relevant
 changes as compared to the previous examination.  Known pleural thickening
 adjacent to the healed right-sided rib fractures.  Unchanged extent of the
 left-sided pleural effusion, the retrocardiac atelectasis, and the slight
 hyperelevation of the left hemidiaphragm.  No focal parenchymal opacities have
 appeared in the meantime.


PATIENT/TEST INFORMATION:


Indication:


Left ventricular function.
Height: (in) 60
Weight (lb): 150
BSA (m2): 1.65 m2
BP (mm Hg): 121/39
HR (bpm): 60
Status: Inpatient
Date/Time: [**2197-1-31**] at 11:51
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


This study was compared to the prior study of [**2196-2-1**].


LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No
ASD by 2D or color Doppler.

LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion
abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting
LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Focal calcifications in
aortic root. Normal ascending aorta diameter.

AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve
leaflets. Moderate AS (AoVA 0.8-1.19cm2). Mild to moderate ([**1-10**]+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of
mitral valve chordae. Mild (1+) MR. Prolonged (>250ms) transmitral E-wave
decel time. Normal LV inflow pattern for age.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA
systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS. No PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.

Conclusions:
The left atrium is normal in size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right ventricular chamber
size and free wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately thickened.
There is moderate to severe aortic valve stenosis (area 0.8-1.19cm2) Mild to
moderate ([**1-10**]+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2196-2-1**], the severity of
mitral regurgitation has increased slightly and estimated pulmonary artery
systolic pressures are higher.


[**2140-1-31**] 11:47 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 1**] # [**Clip Number (Radiology) 1186**]
 Reason: eval NG location
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


63 year old man with AMS, s/p NG placement for PO lactulose for ammonia of 193


REASON FOR THIS EXAMINATION:


eval NG location
 ______________________________________________________________________________


FINAL REPORT


STUDY:  Single portable AP chest radiograph.


INDICATION:


63-year-old male with altered mental status, status post NG tube
 placement.


COMPARISON:


Approximately 2 hours previous.


FINDINGS:


A nasogastric tube is identified coursing through the mediastinum
 with tip in the expected region of the gastric fundus.  The cardiomediastinal
 silhouette is stable in appearance.  There is volume loss in the right lung
 with probable subsegmental right middle lobe atelectasis. The lungs are
 otherwise clear and no effusion or pneumothorax is present.


IMPRESSION:


NG tube with tip in the expected region of the gastric fundus. Right middle
 lobe subsegmental atelectasis.
                                                                       SESHa


PATIENT/TEST INFORMATION:


Indication:


Mitral valve disease.  Coronary artery disease.  Left ventricular function.
Height: (in) 67
Weight (lb): 150
BSA (m2): 1.79 m2
BP (mm Hg): 136/80
HR (bpm): 75
Status: Inpatient
Date/Time: [**2132-6-18**] at 11:30
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No
ASD by 2D or color Doppler.

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Inferobasal LV
aneurysm. Mild regional LV systolic dysfunction. No LV mass/thrombus. False LV
tendon (normal variant). No resting LVOT gradient. No VSD.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular
calcification. Mild (1+) MR. LV inflow pattern c/w impaired relaxation.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.
Borderline PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: No PS.

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium is normal in size. No atrial septal defect is seen by 2D or
color Doppler. There is mild LVH. The left ventricular cavity size is normal.
There is mild regional left ventricular systolic dysfunction with
infero-lateral hypokinesis.There is an inferobasal left ventricular
aneurysm.The LV apex is not well seen however, no obvious masses or thrombi
are seen in the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic hypertension. There
is no pericardial effusion.


Sinus tachycardia.  Left bundle-branch block.  Compared to the previous tracing
of [**2202-1-14**] sinus rhythm has appeared.
TRACING #2


RESPIRATORY CARE NOTE

Patient remains trached with 7.0 Portex DIC trach tube.  PMV removed and cuff inflated with 5cc air at [**2185**].  Combivent mdi given q4 hours.  On 35% trach mask.  Tolerating well as of this time.  Will place PMV back on this AM.

                         [**First Name11 (Name Pattern1) 220**] [**Last Name (NamePattern4) 221**], RRT


Coronary artery bypass graft (CABG)
   Assessment:
   A&O x3. slow to answer questions & prefers to nod.  mae but requires
   encouragement & motivation to do physical activity.  c/o incisional
   pain w/activity.  Nsr w/hr 90
s rare pvc noted.  Sbp 90-130.
   epicardial wires d/c
d prior to change of shift.  Lungs clear but dim
   in bases.  Oft 50% on for [**Last Name (un) 3032**] this am.  Sat
s 95-100%.  Abd obese.
   +bs.  Dtv.  +pp bilat.
   Action:
   Medicated w/ultram at 8am.
   Cont to have rare pvc
   Lopressor dose increased to 75mg [**Hospital1 **].
   Encouraged to use is & cdb.
   +large soft bm.
   Dtv.
   Oob to chair w/encouragement.
   Fs at 8am 92.
   Lantus dose increased to 20units qam.
   Response:
   Reports good effect after ultram
   Tolerating increase dose of lopressor.
   Cont to require encouragement to use IS.
   Oob->chair but c/o dizziness.
   PT worked with patient.
   Plan:
   Pain management.  Cont cardiac rehab.  Encourage pulmonary toilet.
   Increase activity as tolerates.
   Pt voided at 1400 500cc
s of urine. Pt also with stage I to left
   buttocks and [**Doctor First Name 9889**] assessed with RN.  BS at 1645-181 and pt was given
   9 units humalog insulin SC.  Pt currently on 3LO2 NC with sats 98% and
   no stridor noted.  LS-dim throughout and pt encouraged to C&DB and
   continues to need encouragement to use IS.  Pt with Incisional pain
   [**5-15**] and given ultram 50mg at 1645.  Pt resting in chair comfortably at
   this time.
   Demographics
   Attending MD:
   [**Doctor Last Name **] [**Doctor Last Name **] C.
   Admit diagnosis:
   CORONARY ARTERY DISEASE;CHRONIC OBSTRUCTIVE PULMONARY DISEA
   Code status:
   Full code
   Height:
   66 Inch
   Admission weight:
   133.7 kg
   Daily weight:
   138 kg
   Allergies/Reactions:
   Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
   Nausea/Vomiting
   Codeine
   Nausea/Vomiting
   Aspirin
   Nausea/Vomiting
   Precautions:
   PMH:
   CV-PMH:
   Additional


history:


obesity,htn,gerd,dyslipidemia,iddm A1C 9.9%,copd
   uses 3L o2 at night,s/p L thr,new onset cp. cath->mvd,ef 40-45% poor
   quality echo due to size,lvedp ~ 20. baseline creat. 1.4
   Surgery / Procedure and date: [**12-26**] c x  3 lima->lad,vg->om,pda  pre
   T->dilated la & rv. complex atheroma in aortic root,mild mr,mod. tr.
   post T->ef ~ 40% with global rv hk,mod. tr on epi.required neo &
   vasopressin for bp/tone support.av paced for asystole.difficut
   access->[**Location (un) **].closed with talon due to size.
   Latest Vital Signs and I/O
   Non-invasive BP:
   S:93
   D:64
   Temperature:
   96.3
   Arterial BP:
   S:136
   D:121
   Respiratory rate:
   15 insp/min
   Heart Rate:
   94 bpm
   Heart rhythm:
   SR (Sinus Rhythm)
   O2 delivery device:
   Nasal cannula
   O2 saturation:
   98% %
   O2 flow:
   4 L/min
   FiO2 set:
   40% %
   24h total in:
   320 mL
   24h total out:
   1,040 mL
   Pacer Data
   Temporary pacemaker type:
   None
   Pertinent Lab Results:
   Sodium:
   139 mEq/L
   [**2199-12-30**] 02:53 AM
   Potassium:
   4.1 mEq/L
   [**2199-12-30**] 02:53 AM
   Chloride:
   102 mEq/L
   [**2199-12-30**] 02:53 AM
   CO2:
   32 mEq/L
   [**2199-12-30**] 02:53 AM
   BUN:
   14 mg/dL
   [**2199-12-30**] 02:53 AM
   Creatinine:
   1.1 mg/dL
   [**2199-12-30**] 02:53 AM
   Glucose:
   90 mg/dL
   [**2199-12-30**] 02:53 AM
   Hematocrit:
   27.8 %
   [**2199-12-30**] 02:53 AM
   Finger Stick Glucose:
   125
   [**2199-12-30**] 12:00 PM
   Additional pertinent labs:
   Next BS at HS.
   Lines / Tubes / Drains:
   Valuables / Signature
   Patient valuables: None
   Other valuables:
   Clothes:  Sent home with:
   Wallet / Money:
   No money / wallet
   Cash / Credit cards sent home with:
   Jewelry:
   Transferred from: [**Hospital 918**]
   Transferred to: [**Hospital Ward Name 383**] 6
   Date & time of Transfer: [**2199-12-30**] 1800


Resp care
BS equal and generaly clear ( some what Bronchial sounding ).  sxed for sm - mod amount sputum.  Pt remains on A/C although her resp effort indicates she might tolerate a high level of PS/CPAP without dificulty.  Yet her RSBI (163) remains too high to consider aggressive weaning.


[**2158-11-29**] 10:52 AM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 73084**]
 Reason: follow up after right pneumonectomy
 ICD9 code from order: 162.9
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


73 year old man s/p right pneumonectomy with muscle flap


REASON FOR THIS EXAMINATION:


follow up after right pneumonectomy
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


73 year old man status post right pneumonectomy with muscle flap.
 Follow up chest x-ray.


COMPARISON:


Upright AP portable chest x-ray of [**2158-11-6**].


TECHNIQUE:


PA and lateral chest x-ray.


FINDINGS:


Again seen are stable postoperative changes with shift of the
 mediastinum to the right with opacification of the right hemithorax status
 post pneumonectomy.  The wires are in similar position.  There are unchanged
 deformities of the right lateral ribs from the prior surgery.  The pacemaker
 remains in unchanged position.  Since the prior study, the post pyloric
 feeding tube has been removed.  There are small persistent linear opacities in
 the left mid and lower lung zones consistent with atelectasis or scar, but the
 lungs is otherwise clear on the left.  There is continued slight blunting of
 the left costophrenic angle.  No pneumothorax is seen.  The appearance of the
 osseous structures and soft tissues are unchanged.


IMPRESSION:


1.  Stable postoperative changes.

 2.  Persistent linear opacities suggesting minor atelectasis or scarring at
 the left lung.

 3.  Removal of feeding tubes since the prior study.


Subdural hemorrhage (SDH)
   Assessment:
   Action:
   Response:
   Plan:


88 year old male who has history of bladder CA who presented with
   septic shock and respiratory failure who had difficulty weaning from
   the ventilator.  He also had acute renal failure requiring dialysis and
   would have needed trach and PEG if we were continue to treat him.
   Family meeting occurred [**6-27**] with team and social work and pt
s wife who
   determined that pt would not want to live a poor quality of life and
   given his grim prognosis he was made CMO. Pt was extubated last evening
   and all meds were stopped except for morphine drip. Dialysis is
   stopped.
   Pt required increased morphine drip overnight to 27mg/hr to make him
   comfortable. His wife and her friend have been at his side all night.
   He has had agonal respirations all shift with stable HR/BP and O2 sats
   on room air. He has had some periods with BP dropping to 70
s in the
   past few hours.
   Pt remains comfortable on morphine drip with his wife at his side.
   Mouth care done twice and pt turned once as his wife requests minimal
   stimulation.
   Continue to provide comfort care for pt and emotional support to
   family.


SOCIAL WORK NOTE ADDENDUM:
Faxed guardianship information sheet and medical certificate from Dr. [**Last Name (STitle) **] to legal department for f/u as needed.  Pager [**Numeric Identifier 238**].


Sinus rhythm
LVH with secondary ST-T changes
Since last ECG, no significant change


[**2177-9-19**] 9:38 AM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 26**] # [**Clip Number (Radiology) 2929**]
 Reason: Please confirm NGT placement. Thanks,
 Admitting Diagnosis: ISCHEMIC COLITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


86 year old woman with confirm NGT placement.


REASON FOR THIS EXAMINATION:


Please confirm NGT placement. Thanks,
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


NG placement.


FINDINGS:


In comparison with the earlier study of this date, there has been placement of
 a nasogastric tube that extends well into the stomach, with the side hole
 below the esophagogastric junction level.  Central catheter remains in place
 and the appearance of the heart and lungs is unchanged.


[**2104-4-23**] 10:46 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 31215**]
 Reason: eval for pneumonia in patient with rising WBC
 Admitting Diagnosis: AORTIC VALVE VEGETATION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


56 year old man s/p Bental, ascending aorta replacement


REASON FOR THIS EXAMINATION:


eval for pneumonia in patient with rising WBC
 ______________________________________________________________________________


FINAL REPORT


CHEST RADIOGRAPH.


INDICATION:


Ascending aorta replacement, rising white blood cell count.


COMPARISON:


[**2104-4-21**].


FINDINGS:


As compared to the previous radiograph, the monitoring and support
 devices are in unchanged position.  There is unchanged evidence of bilateral
 pleural effusions, combined to basal areas of atelectasis.  These areas of
 atelectasis are unchanged.  Given the limitations of the conventional chest
 radiograph, however, coexisting pneumonia cannot be excluded.  The appearance
 of the cardiac silhouette is constant.  No evidence of pneumothorax.


[**Last Name (LF) 13399**],[**First Name3 (LF) 8742**] R.                   MED CC7A                   [**2142-6-5**] 11:41 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 54947**]
 Reason: r/o infiltrate, effusion
 Admitting Diagnosis: FALL/ DYSPHAGIA
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


80 year old man with acute SOB


REASON FOR THIS EXAMINATION:


r/o infiltrate, effusion
 ______________________________________________________________________________
                                  PFI REPORT
 PFI:  No pneumothorax, marked cardiomegaly as before, amount of pleural
 effusion increases particularly along the right lateral chest wall.


NICU nursing note


4.  FEN=O/Current wt=1110g (down 5g).  Remains NPO.  TF cont
at 120cc/k/d of PND10 with lipids via patent/intact PIV LUE.
Transfused 20cc/k PRBC at [**2188**] via patent/intact scalp PIV.
Abd benign.  Girth 19.5-20cm.  No loops.  (Please refer to
flowsheet for assessment.)  No spits.  U/O=5.2cc/k/hr for
first 8hrs of shift.  No stool.  Next KUB scheduled for
0400.  TCH surgery in to assess pt at 0200.  A/Alt in FEN.
P/Cont to monitor FEN status.

6.  G&D=O/Temp stable swaddled in air isolette.  [**Year (4 digits) 25**] and
active with cares.  Sleeping well in between.  MAE.  Font
S/F.  No s/sx pain/discomfort.  A/Alt in G&D.  P/Cont to
monitor and support G&D.

7.  [**Year (4 digits) **]=O/Mom and dad in to visit.  Both weepy.  Fully
updated by this RN.  A/appropriate and actively involved.
P/Cont to support and educate [**Year (4 digits) **].

10.  A/B's=O/No spells so far this shift.  A/Stable in room
air.  P/Cont to monitor for A/B's.

11.  I/D=O/Cont on Amp, Gent, and Clindamycin.  A/triple ABX
tx secondary to NEC.  P/Cont with current Rx.


NICU Fellow
comfortable
NC, AFOF
Lungs clear and equal, mild subcostal retraction
S1S2 normal, no murmur RRR
Abd soft, non distended, active
MAEW, pink, appr tone


Sinus rhythm.  Low lateral precordial lead QRS voltage and low T wave amplitude
are non-specific and may be within normal limits.  Since the previous tracing
of [**2103-7-25**] the rate is faster and findings as outlined are now present.


PATIENT/TEST INFORMATION:


Indication:


Aortic valve disease. Endocarditis.
Height: (in) 61
Weight (lb): 110
BSA (m2): 1.47 m2
BP (mm Hg): 94/60
HR (bpm): 98
Status: Inpatient
Date/Time: [**2134-12-2**] at 13:38
Test: Portable TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Good


INTERPRETATION:


Findings:


Patient was intubated and sedated with propofol during the procedure.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.

LEFT VENTRICLE: Overall normal LVEF (>55%).

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Focal calcifications in aortic root. Complex (>4mm) atheroma in the
aortic arch. Simple atheroma in descending aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Probable aortic
valve vegetation. Filamentous strands on the aortic leaflets c/with Lambl's
excresences (normal variant). No aortic valve abscess. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on
mitral valve. Mild mitral annular calcification. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on
tricuspid valve.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No
vegetation/mass on pulmonic valve.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the
location listed above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) 1**] [**Last Name (Titles) 2**] throughout the
procedure. The patient was under general anesthesia throughout the procedure.
No glycopyrrolate was administered. No TEE related complications. Results were
personally reviewed with the MD caring for the patient.

Conclusions:
No atrial septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is normal (LVEF>55%). Right ventricular chamber
size and free wall motion are normal. There are complex (>4mm), non-mobile
atheroma in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is a
12 x 3mm mobile echodensity on the aortic side of the left cusp of the aortic
valve that is suspicious for a vegetation. There are filamentous strands on
the aortic leaflets consistent with Lambl's excresences (normal variant). No
aortic valve abscess is seen. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.


IMPRESSION:


12 x 3 mm mass on the aortic valve concerning for vegetation in
the correct clinical context. There are some atypical features in that the
mass does not prolapse back into the LVOT and no aortic regurgitation is seen.
Mild mitral regurgitation. Atheromatous aorta.

Dr. [**Last Name (STitle) 583**] was notified in person of the results on [**2134-12-2**] at 12:30.


[**2158-5-26**] 8:22 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 81423**]
 Reason: ischic/ich
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


81 year old man with left face and arm numbness, h/o right carotid plaque


REASON FOR THIS EXAMINATION:


ischic/ich
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: KLMn FRI [**2158-5-26**] 9:50 PM
  no hemorrhage or mass effect
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


81-year-old man with left face and arm numbness.  History of
 right carotid plaque.


COMPARISON:


[**2158-5-23**].


TECHNIQUE:


Non-contrast head CT.


FINDINGS:


There is no hemorrhage, edema, mass effect, hydrocephalus, or acute
 vascular territorial infarct.  The prominence of ventricles and sulci is
 unchanged, consistent with involutional change, as well as mild bifrontal
 extra-axial prominence. No fractures are seen. Paranasal sinuses, mastoid air
 cells, and middle ear cavities are clear. Soft tissues are unremarkable.


IMPRESSION:


No hemorrhage or mass effect.


Newborn Med Attending

Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. DS=40s all night, but now in 50s. Bili=10.4. Wt=3475 down 30. Taking 20 cc per feeds.
A/P: IDM still requiring IV glucose to maintain adequate BS. Cont to wean IVF for DS>60. Encourage PO feeds.


[**2116-7-10**] 5:26 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 26**] # [**Clip Number (Radiology) 104041**]
 Reason: any pulm edema?
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


37 y.o male with no significant pmhx was walking home from [**Last Name (un) **] [**Doctor Last Name **] when he
  fell down and felt weak and found to be hyperglycemic and have LLL
  consolidation, anion gap metabolic acidosis.


REASON FOR THIS EXAMINATION:


any pulm edema?
 ______________________________________________________________________________
 WET READ: OXZa FRI [**2116-7-10**] 6:22 PM
  left lower and mid consolidation with likely parapneumonic effusion. follow up
  after treatment is recommended. right lung is clear. no overt pulmonary edema.
 ______________________________________________________________________________


FINAL REPORT


PORTABLE CHEST, [**2116-7-10**]


COMPARISON:


Radiograph of earlier the same date.


FINDINGS:


Left mid and lower lung consolidation has progressed since the
 prior radiograph, and a newly demonstrated horizontal interface is present
 peripherally in the left mid chest at the level of the left third anterior
 rib.  This is concerning for an air-fluid level and could potentially
 represent a loculated hydropneumothorax.  Cardiomediastinal contours are
 within normal limits allowing for partial obscuration of the left heart border
 by the adjacent consolidation and effusion.  Right lung and pleural surfaces
 are clear.  Mild to moderate gastric distention has developed in the upper
 abdomen.


IMPRESSION:


Progressive consolidation in left mid and lower lung consistent
 with evolving pneumonia.  New air-fluid level peripheral to the consolidation
 is concerning for a loculated hydropneumothorax.  This finding has been
 communicated by telephone to Dr. [**Last Name (STitle) **] on [**2116-7-11**] at 9 a.m. at the
 time of discovery.


Neonatology Attending Note
Day 14
CGA 36 1

RA. RR40-60s. Cl and = BS. No A&Bs, but will have sat drifts to mod 80s. Mild sc rtxns. No murmur. HR 130-180s. BP 75/41, 52.

Wt 2040, down 10. TF 150 BM24 po>pg.  [** **] well. Nl voiding and stooling.

In open crib.

A/P:
Growing preterm infant.
 -- awaiting maturation of resp pattern
 -- encourage po skills, follow growth


[**2101-5-19**] 8:52 PM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # [**Telephone/Fax (1) 20854**]
 Reason: ? pulmonary embolism
 Admitting Diagnosis: MORBID OBESITY/SDA
  Contrast: OPTIRAY Amt: 130
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


28 year old woman s/p open Gastric Bypass and CCY


REASON FOR THIS EXAMINATION:


? pulmonary embolism
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


28-year-old woman status post open gastric bypass and
 cholecystectomy.  Question pulmonary embolism.


COMPARISON:


Upper GI from [**2101-5-19**].


TECHNIQUE:


MDCT images were acquired through the chest, abdomen, and pelvis
 with IV contrast.  Multiplanar reformations were obtained and reviewed.

 CT OF THE CHEST WITH IV CONTRAST:

 Evaluation is limited due to body habitus and streak artifact from the gantry.
 Within these limitations, there is no large central main pulmonary artery PE.
 Evaluation of the segmental and subsegmental branches is limited due to bolus
 timing and streak artifact.  The heart and great vessels are unremarkable.
 There is a small right-sided pericardial fluid collection (2A:58), which could
 represent a pericardial cyst or a bronchogenic cyst.  The lungs show no
 nodules, effusions, or consolidations.  There is mild bibasilar atelectasis.

 CT OF THE ABDOMEN WITH IV CONTRAST:

 The patient is status post recent gastric bypass surgery.  No contrast is
 noted in the peritoneal cavity.  The liver, spleen, both adrenals, both
 kidneys, pancreas are unremarkable.  The patient is status post
 cholecystectomy.  A drain is noted in the right upper quadrant appropriately.
 The small bowel loops are mildly prominent, likely representing ileus.  The
 large bowel is unremarkable.  No free fluid or air noted.

 CT OF THE PELVIS WITH IV CONTRAST:

 The rectum, sigmoid colon and bladder are unremarkable.  No pelvic or inguinal
 lymphadenopathy or pelvic free fluid is present.

 OSSEOUS STRUCTURES:

 The visible osseous structures show no suspicious lytic or blastic lesions or
 fractures.


IMPRESSION:


1.  No large central PE.  Evaluation of segmental and subsegmental branches is
                                                             (Over)

 [**2101-5-19**] 8:52 PM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # [**Telephone/Fax (1) 20854**]
 Reason: ? pulmonary embolism
 Admitting Diagnosis: MORBID OBESITY/SDA
  Contrast: OPTIRAY Amt: 130
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 limited.

 2.  Post gastric bypass.  No evidence of leak.


NEURO: PT SEDATED, DILAUDID DECREASED TO 1MG/HR, PT OCCASIONALLY OPENS EYES TO VOICE, WITHDRAWS TO TACTILE STIMULE, MOVING ALL EXTREMITIES PURPOSFULLY, PUPILS 3MM BRISK, UNABLE TO FOLLOW COMMANDS,
CV: TMAX 100.8, HR 70-90'S NSR WITH NO ECTOPY. SBP 80-100, NEO TITRATED TO KEEP MAP>50, PRESENTLY AT 0.8MCG/KG/MIN.  CVP 10-14. EXTREMITIES WARM, PALPABLE PERIFERAL PULSES.UPPER EXTREMITIES REMAIN 3RD SPACED WITH MOD AMOUNT OF WEEPING.
RESP: PT REMAINS ON CPAP+PS. PT TOLERATING WELL. RESP 13-20. LUNGS COARSE THROUGH OUT, SUCTIONED OF SMALL AMOUNT OF WHITE THIN SPUTUM,O2 SATS 98%
SKIN: ABDOMEN FIRMLY DISTENDED. ABDOMINAL INCISION OPEN. TISSUE SURROUNDING INCISION BLACK IN COLOR. WOUND BED DARK RED,APPEARS TO BE APPROX. BILAT HEEL WITH RED AREAS MULTIPODUS BOOTS.
GU: URINE OUTPUT 100+ CC Q HR. YELLOW WITH SEDIMENT.


PATIENT/TEST INFORMATION:


Indication:


Coronary artery disease. ASD? Bubble
Height: (in) 67
Weight (lb): 125
BSA (m2): 1.66 m2
BP (mm Hg): 109/48
HR (bpm): 55
Status: Inpatient
Date/Time: [**2141-12-26**] at 11:18
Test: Portable TTE (Congenital, complete)
Doppler: Full Doppler and color Doppler
Contrast: Saline
Technical Quality: Adequate


INTERPRETATION:


Findings:


This study was compared to the report of the prior study (images not
available) of [**2136-4-11**].


LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter
(<2.1cm) with >55% decrease during respiration (estimated RA pressure
(0-5mmHg).

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%). No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta
diameter. Normal aortic arch diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.

MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline
PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.
Physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs
of agitated normal saline, at rest, with cough and post-Valsalva maneuver.

Conclusions:
The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg.
There is mild symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.

There was borderline early passage of agitated saline contrast into the left
heart with Valsalva release which is consistent with intracardiac shunt
suggestive of a probable patent foramen ovale (versus pulmonary arteriovenous
communication).

Compared with the report of the prior study (images unavailable for review) of
[**2136-4-11**], estimated pulmonary artery systolic pressure is now higher.


Respiratory Care Note:
   Patient remains intubated and weaning on PSV. Propofol off and she remains asleep. Respirations appear slightly labored with # 7.0 ET tube in. BS=bilat, diminished. Suctioned for small to med amounts of thick yellow. Possible extubation today.


TITLE:
   Demographics
   Day of intubation:
   Day of mechanical ventilation: 0
   Ideal body weight: 52.2 None
   Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg
   Airway
   Airway Placement Data
   Known difficult intubation:
   Procedure location:
   Reason: NIV
   Tube Type
   ETT:
                   Position:  cm at teeth
                   Route:
                   Type:
                   Size:
   Tracheostomy tube:
                   Type:
                   Manufacturer:
                   Size:
                   PMV:
   Cuff  Management:
                   Vol/Press:
                                   Cuff pressure:   cmH2O
                                   Cuff volume:   mL /
                   Airway problems:
                   Comments:
   Lung sounds
   RLL Lung Sounds: Diminished
   RUL Lung Sounds: Clear
   LUL Lung Sounds: Clear
   LLL Lung Sounds: Diminished
   Comments:
   Secretions
   Sputum color / consistency:  /
   Sputum source/amount:  /
   Comments:
   Ventilation Assessment
   Level of breathing assistance: Intermittent non-invasive ventilation
   Visual assessment of breathing pattern: Normal quiet breathing
   Assessment of breathing comfort: No claim of dyspnea)
   Non-invasive ventilation assessment: Tolerated well
   Invasive ventilation assessment:
   Trigger work assessment:
   Dysynchrony assessment:
   Comments:
   Plan
   Next 24-48 hours: continuing with NIV through PM in order to rest pt...
   plan to revaluate in AM rounds
   Reason for continuing current ventilatory support: Intolerant of
   weaning attempts
   Respiratory Care Shift Procedures
   Transports:
   Destination (R/T)
   Time
   Complications
   Comments
   Bedside Procedures:
   Comments:


[** 41**] ON-Call
Please see Dr.[**Doctor Last Name 132**] note for overall summary and plan

Physical Exam
General: infant in isolette, room air
Skin: warm and dry; color pinkm jaundiced
HEENT: anterior fontanel open, level; sutures opposed
Chest; breath soudns clear/=
CV: RRR, no murmur normal S1 S2; pulses +2
Abd: soft; no masses; + bowel sounds; cord on/drying
GU: normal male; testes descending
Ext: moving all
Neuro: + suck; + grasps; symmetric tone


Resp Care Note,Pt rested overnight on A/C for increased WOB.Agitated most of night. Sedated with Fentanyl and Haldol.Suctioned for mod amts [** **] white secretions. MDI'S given. RSBI done on 0 peep/5 ips 97.6. ABG'S good will cont to wean as [** **]. Monitor resp status.


[**2155-8-29**] 6:13 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 24809**]
 Reason: Is there evidence of pleural effusion or infiltrate?
 Admitting Diagnosis: ENDOCARDITIS
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


54 year old man transfered from outside hospital with report of sizeable left
  sided pleural effusion and endocarditis on OSH ECHO


REASON FOR THIS EXAMINATION:


Is there evidence of pleural effusion or infiltrate?
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Outside report regarding left-sided pleural effusion.

 CHEST, SINGLE AP PORTABLE VIEW:  Lordotic positioning.  A left-sided pacemaker
 is present with a large electronic component, which obscures portions of the
 left mid zone.

 There is moderately severe cardiomegaly.  There is upper zone redistribution
 and diffuse vascular blurring.  There is marked increased opacity at the left
 lung base with obscuration of the left hemidiaphragm, consistent with left
 lower lobe collapse and/or consolidation.  There is atelectasis and/or minimal
 patchy opacity at the right lung base.  Small bilateral effusions cannot be
 excluded.


Neonatology Note
PE: in open crib, RA
pink active with exam
AFOF, no cleft lips, palate
RR with no murmur, pulses equal
slightly tachypneic, comfortable, braeth sounds equal, good air exchange
abdomen soft no mass palpable, BS present
normal external genitalia.
Normal tone, good sucking

CXR normal heart size, no consolidation
will d/c antibiotics.


CVA (Stroke, Cerebral infarction), Ischemic
   Assessment:
   -pt. continues to open eyes to command, moves LUE well, moves LLE on
   bed, no movement noted with RUE, minimal movement with RLE.
   -PERRL 3-4mm bilat
   -pt. continues with garbled speech, mostly perseverates with
   -very weak gag, impaired cough, pt. unable to clear secretions
   - NA continues to remain in 150
   -Pt. remains on Heparin gtt. Goal PTT increased to 55-65
   Action:
   -q 4 neuro checks
   -frequent sx. And mouth care to clear sx.
   -Heparin gtt. Increased to 750units/hr
   Response:
   -Pt. continues with weak gag, humidified O2 on 100%
   Plan:
   -continue q 4 neuro checks
   -HOB>30
   -speech and swallow in am, ?trip to IR for possible advancement of
   Dophoff post-pyloric if pt. fails speech and swallow
   -continue free water flushes
   -repeat head CT in am
   -Check PTT and lytes @ [**2122**]
   Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway
   Clearance, Cough)
   Assessment:
   Action:
   Response:
   Plan:


ECG interpreted by ordering physician.
[**Name10 (NameIs) 2**] see corresponding office note for interpretation.


Neuro: Normal thermic. Reversed, weaned propofol off. Able to follow commands appropriately. Opens eyes spontaneously. L pupil pinpoint, R pupil 2mm, PA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 58**] examined pt at bs, no tx ordered at this time. MAEx4 spontaneously and to command. No deficit.

C/V: NSR w/occasional PACs/PVCs. Multiple 4-5 beat runs of PVCs. Lytes repleated. Pacer off d/t inappropriate sensing. Post-op EKG showed ST depression, PA [**Last Name (NamePattern4) **] made aware. ?sinus arrythmia vs PACs, repeat EKG & AEG confirmed sinus rhythm. Finishing plt infusing. Coags elevated, pt oozy, 2 FFP infused & DDAVP admin per order, increased PEEP-->coags WNL, CT output slowed.  Hct 28, 1 PRBCs infused. Titrated levophed to keep SBP >90-<120. SVo2s 60-70s, CI >2 by fick. Dopperable pulses. Skin w&d.

Resp: Remains on SIMV. Weaning vent w/good ABG, see carevue. Kept intubated overnight per PA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 58**]. Plan for CPAP trial in am, extubation as tol.  LS CTA. ETT repositioned lower by RT per PA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 58**].

Gi/Gu: NPO. OGT to LCS. Hypoactive BSx1, absent x3. Foley w/adequate HUO.

Skin: See carevue for incisions. JP in R leg draining serosanginous fluid. BLE w/2+ edema (PMH venoustasis). Bruises on abd??, 3rd/4th toes on R foot w/discoloration, not new.

Endo/ID: Started insulin gtt. Titrating per CSRU protocol. Low grade temp, on scheduled IV antibiotics.

Act/Comfort: Repo in bed w/2 assist, tol well. IVP MSo4 for incisional pain w/mod effect. Daughter & son updated by PA and RN, visited w/pt. All procedures explained to pt.

A/P: Wean vent to extubate. Pulmonary toilet. Monitor hemodynamics & rhythm. ?start diuretic in am. Transition insulin gtt to sliding scale as tol.


Demographics
   Day of intubation:
   Day of mechanical ventilation: 0
   Ideal body weight: 0 None
   Ideal tidal volume: 0 / 0 / 0 mL/kg
   Airway
   Airway Placement Data
   Known difficult intubation:
   Procedure location:
   Reason:
   Tube Type
   ETT:
                   Position:  cm at teeth
                   Route:
                   Type: Standard
                   Size: 7.5mm
   Tracheostomy tube:
                   Type:
                   Manufacturer:
                   Size:
                   PMV:
   Cuff  Management:
                   Vol/Press:
                                   Cuff pressure:   cmH2O
                                   Cuff volume:   mL /
                   Airway problems:
                   Comments:
   Lung sounds
   RLL Lung Sounds: Diminished
   RUL Lung Sounds: Clear
   LUL Lung Sounds: Clear
   LLL Lung Sounds: Diminished
   Comments:
   Secretions
   Sputum color / consistency: Yellow / Thick
   Sputum source/amount: Suctioned / Small
   Comments:
   Ventilation Assessment
   Level of breathing assistance:
   Visual assessment of breathing pattern:
   Assessment of breathing comfort:
   Non-invasive ventilation assessment:
   Invasive ventilation assessment:
   Trigger work assessment:
   Dysynchrony assessment:
   Comments:
   Plan
   Next 24-48 hours:
   Reason for continuing current ventilatory support:
   Respiratory Care Shift Procedures
   Transports:
   Destination (R/T)
   Time
   Complications
   Comments
   Bedside Procedures:
   Comments:
   Patient extubated placed on cool mist then switched to N/C. Alert ,coop


Intracerebral hemorrhage (ICH)
   Assessment:
    Patient continues with poor neuro exam,  unresponsive , does not open
   eyes or follow commands when off propofol  drip for assessment.
   Withdrawing with lower ext. ,  does not withdraw with upper
   extremities. No spontaneous  movement noted. +corneals. Pupils briskly
   reactive 2-3mm bilaterally. Noted to yawn frequently. Bilateral EVDs 10
   @ tragus, patent for clear CSF, ICPs [**5-4**].  SBP <140 with IV Labetolol
   PRN.  Initially not over-breathing vent w/PC02s 21-24, through day pt.
   taking more breaths over vent.
   Action:
   Neuro checks hourly, SBP kept <140 per neurosurg, Nimodopine for
   vasospasm prevention, mult vent changes made and sedation titrated.
   Repositioned for comfort.
   Response:
   SBP stable <140, increase in PC02 to 28-30.
   Plan:
   Cont. to monitor closely, blood pressure control, check ABGs as needed,
   if pt. remains stable overnight will have angio in am followed by
   another family meeting to discuss findings.


NPN Days


#2 [**Name (NI) 1**] Pt received and cont in RA LS C+=. mild IC SC
retrac. no spells so far this shift. occ. drift to the 80's
QSR. Pt cont on caffine. P- Will cont to monitor Resp
status.
#3 FEN- TF=150cc/kg/d of BM22. abd benign. voiding, trace
stool. one sm spit. min asp. P- Will cont to monitor FEN.
#4 [**Name (NI) 572**] Dad called once this shift. [**Name (NI) 2**] will be in
later this shift. Loving and caring. asking approp ques.
updates given. P- Will cont to monitor FEN.
#5 G&D- Temp stable in servo isolette. alert and active with
cares. sucking on pacifier. settles well with boundaries. P-
Will cont to monitor G&D.
See flowsheet for further details.


Atrial demand pacing. Atrio-ventricular conduction delay. Slight ST segment
elevation in the anterior leads with corresponding T wave inversions, most
consistent with an evolving anterior wall myocardial infarction. Compared to
the previous tracing of [**2198-7-7**] atrial pacing is now evident. There are
persistent abnormalities in the anterolateral leads. These are less pronounced
and are consistent with evolving anterior wall myocardial infarction.


[**2197-8-30**] 9:56 AM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 40965**]
 Reason: assess for any changes
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


25 year old woman with subdoral hematoma


REASON FOR THIS EXAMINATION:


assess for any changes
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


STUDY DATE:  [**2197-8-30**].


INDICATION:


Subdural hematoma, followup evaluation.


COMPARISON:


CT head done on [**2197-8-23**].


TECHNIQUE:


Non-contrast CT head.


FINDINGS:


There is a mixed attenuation extra-axial ( subdural) left-sided fluid
 collection, along the convexity, in the frontal, parietal and temporal
 regions, with mild displacement of the cerebral hemisphere towards the right
 side and mild shift of the midline structures towards the right side by 6 mm.
 There is mild decrease in the previously noted dense areas in the collection,
 which may relate to evolution of the blood products.  The maximum transverse
 dimension of the collection is measuring approximately 8 mm, not significantly
 changed compared to the prior study allowing for the technical differences.
 No new areas of acute hemorrhage are noted.  There is mild mass effect on the
 left lateral ventricle, not significantly changed.

 No suspicious lytic or sclerotic lesions are noted.  The soft tissues of the
 scalp are otherwise unremarkable.  The imaged portions of the paranasal
 sinuses and the mastoid air cells are clear.  There is pneumatization of the
 petrous apex on the right, along with possible opacification of the
 pneumatized petrous apex on the left side.
 Please see the osseous details on the prior study of [**2197-8-19**] which revealed a
 fracture through the temporal bone on the left side and at skull base.


IMPRESSION:


1.  Evolving, subacute left-sided subdural hemorrhage, with no significant
 change in the size and mass effect.  Persistent few areas of increased
 attenuation which relate to acute-subacute hemorrhage.  No new hemorrhage
 elsewhere.  See the prior study of [**2197-8-19**] for details regarding the
 fractures.  Follow up as clinically indicated.


Respiratory care:
Patient intubated with a 7.5 ETT taped and secured at 23 cm. Breathsounds are coarse but equal. ETCo2 checked with easy cap. CXR done, ETT in good position. Vent settings: a/c 500*16 60% and 5 peep.
Patient transported to CT and back on vent without incident. Please see respiratory section of carevue for data.
Plan: Continue mechanical ventilation. Wean as tolerated.


Chief Complaint:
   24 Hour Events:
 PICC LINE - START [**2201-6-26**] 03:04 PM: Needs IR confirmation of PICC
   placement
 FEVER - 101.7
F - [**2201-6-27**] 04:00 AM: Pan-cultured
   Allergies:
   Penicillins
   Hives; Shortnes
   Ciprofloxacin
   Hepatic toxicit
   Last dose of Antibiotics:
   Metronidazole - [**2201-6-26**] 12:47 PM
   Acyclovir - [**2201-6-27**] 01:15 AM
   Meropenem - [**2201-6-27**] 01:15 AM
   Vancomycin - [**2201-6-27**] 08:00 AM
   Infusions:
   Midazolam (Versed) - 0.5 mg/hour
   Fentanyl - 125 mcg/hour
   Other ICU medications:
   Furosemide (Lasix) - [**2201-6-26**] 11:32 AM
   Pantoprazole (Protonix) - [**2201-6-26**] 08:00 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  [**2201-6-27**] 08:20 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.7
C (101.7
   Tcurrent: 37.4
C (99.4
   HR: 96 (95 - 106) bpm
   BP: 113/72(86) {105/69(83) - 151/100(115)} mmHg
   RR: 15 (14 - 18) insp/min
   SpO2: 95%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 70 Inch
           Total In:
                                                                  2,174 mL
                                                                  1,436 mL
   PO:
           TF:
   IVF:
                                                                  2,174 mL
                                                                  1,196 mL
   Blood products:
   240 mL
   Total out:
                                                                  3,430 mL
                                                                    520 mL
   Urine:
                                                                  3,430 mL
                                                                    520 mL
   NG:
   Stool:


NPN 7A7P


RESP
INFANT IN RA WITH ADEQ SATS. LSC. BASELINE MILD RTXS. ON
LASIX. AWAIT [** **] FOR DC HOME AND MOM WILL DELIVER LASIX
DOSE. NO BRADYS NO DESATS. WILL BE FOLLOWED IN PULMONARY
CLINIC AT CH. PLAN DC HOME TODAY.
FEN
INFANT ON [** **] DEMAND OF [**Doctor Last Name **] 20. BOTTLES 100-120 CC EVERY
3-4 HRS USING YELLOW NIPPLE. SHE GULPS SO SHE NEEDS PACING
AT START OF EACH FEEDING. ABD SOFT WITH ACTIVE BS. VOIDING.
NO SPITS. LRG UMBI HERNIA, SOFT AND REDUCABLE. MONITOR
WEIGHT AND EXAM. TO BE FOLLOWED BY PEDI.
G/D
INFANT IN OAC WITH STABLE TEMPS. A/A FOR CARES. LIKES TO BE
HELD OR ENTERTAINED. SUCKS ON PACIFIER. HANDS TO FACE. HX
GRADE 2 IVH, TO BE FOLLOWED BY NEONATAL NEURO AT CH, FU IN 6
MOS. MONITOR AND SUPPORT G/D.
PARENTING
PLANNED DC HOME TODAY. AWAITING [**Doctor Last Name **]. ALL DC TEACHING
DONE. WILL REVIEW LASIX ADMINISTRATION AND CARSEAT
PLACEMENT. SUPPORT [**Doctor Last Name **] AS THEY PLAN TO BRING THIS INFANT
HOME.


Sinus rhythm, rate 80. Since the previous tracing of [**2141-4-13**] there is no change.


TITLE:
   Chief Complaint:
   24 Hour Events:
   - Discussed case with cards consult, suggested amiodarone bolus and


Sinus rhythm. Modest right ventricular conduction delay pattern. Low
QRS voltage. Delayed R wave progression. Precordial lead T wave abnormalities.
Cannot exclude myocardial ischemia. Findings are non-specific but clinical
correlation is suggested. No previous tracing available for comparison.


Nursing progress notes
Review of systems:

Neuro: pt alert oriented x 2 pleasant c/o some general body aches when being turned and repositioned. perl 3mm brisk

Resp: 02 on 2liters nc sats 98-100% ls clear w/ diminished bases right side is more diminished than left. pt has a dry cough states " there's something there that won't come up"

CV: tele sr 80-90 bp wnl, pedal pulses +3 radial pulses +3 pt has upper and lower extremity edema. hct last evening 25.5 (down from 25.8) at 2300 25.3 at 0300 24.3, Plt at 1900 157 (down from [**Telephone/Fax (5) 8882**], this am 147 Dr. [**First Name8 (NamePattern2) 8883**] [**Last Name (NamePattern1) **] aware no orders given. pt had a small amount of epitaxis this am while blowing her nose. Eccymosis noted around 2 piv sites and under right arm and on left inner thigh, also on left upper and lower arm. all eccymotic areas have become a little larger overnight. Dr [**Last Name (STitle) 8884**] aware no orders given. ion ca 1.15, the rest of lytes are pending. k and mag where low last evening and replaced w/ 40meq kcl and mg 1.8 repleated w/ 2 gms of mag in 100cc. hrt sounds s1s2. pt cont on heparin for massive bilat pe and non-occlusive dvt in right leg. heparin off x 1hr and decreased by 500u for ptt of 120.6 last ptt at 0330 93 therapuetic. HIT antibody drew this am d/t dropping hct and plt.


gi: pt taking po liquids well, she is a vegitarian her husband will bring in food for her to eat however she has stated she would eat jello. abd soft bs + no stool this shift.

gu: foley draining amber colored urine. qs

skin: eccymosis as stated above.

code full

endo: fingersticks q 1hr insulin gtt is currently off d/t bs of 70 last bs 104 at 0500

id: bc and urine cx pending

social: pt husband and [**Name2 (NI) 163**] visited pt last evening. social worker to visit pt in am re emotional stress and financial stress.

access: 3 piv and one femoral 3 lumen tlcl. site oozing bldy drainage from tlcl dsg changed.

Plan:
?ivc filter d/t right leg clot and massive pe.
finger sticks q 1hr titrate to keep bs 120s.
cont to monitor for bleeding from lines sites
next ptt at 0900


[**2120-12-9**] 1:41 PM
 CT TRACHEA W/O C W/3D REND                                      Clip # [**Clip Number (Radiology) 72897**]
 Reason: EVAL TBM
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


59 year old woman with TBM


REASON FOR THIS EXAMINATION:


eval
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


REASON FOR EXAM:


History of tracheal bronchomalacia status post tracheal
 bronchoplasty.  Followup exam.


COMPARISON:


CT trachea from [**2120-4-19**], chest radiograph from [**2120-11-19**].


TECHNIQUE:


Multidetector CT images of the chest without administration of IV
 contrast with 5-mm and 1.25-mm axial slices in inspiration and expiration were
 submitted for interpretation.


FINDINGS:


The trachea just above the aortic arch measures 251 mm2 on
 inspiration, 141 mm2 expiration and 88 mm2 on prior exam at the same level.
 The proximal right main stem bronchus measures 5 mm on the expiratory image
 and measured 2 mm on prior exam at the same level. The right main stem
 bronchus decreases from 6 mm to 1 mm from inspiratory to expiratory images.
 The right upper lobe bronchus collapses to up to 1 mm in diameter on
 expiratory image with completely collapsed on prior exam.  The bronchus
 intermedius measures 4 mm on expiratory image where it completely collapsed on
 prior exam. The left main stem bronchus measures 7 mm proximally where it
 measured 5 mm on prior exam.  Mid-to-distal left main stem bronchus measures 5
 mm, stable since prior exam.  Significant collapse of left lower lobe bronchus
 is minimally decreased or stable since prior exam.  The left upper lobe
 bronchus does not collapse and stable since prior exam.  Interval flattening
 and increased thickening of the posterior wall of the trachea and main stem
 bronchi is compatible with recent tracheal bronchoplasty and mesh placement.
 On expiratory images, there is no significant air trapping.  This is a
 significant change since prior exam where there was diffuse air trapping.
 There is no pneumothorax, pleural effusion or focal pulmonary consolidation.
 Mild linear atelectasis/scarring in the right lower lobe as well as mild
 atelectatic changes in the right middle lobe are noted. A few 2-3 mm pulmonary
 nodules are stable (these are on images 4:77, 85, 119).Two calcified
 granulomas on images 4:143 and 4:240 are stable.


 Imaged thyroid gland appears unremarkable.  There is no mediastinal, hilar or
 axillary lymphadenopathy.  Atherosclerotic calcifications of the aorta are
 mild.  Heart is not enlarged.  There is no pericardial effusion. Incidentally
 noted is a right proximal carotid artery stent, stable.

 Partially imaged upper abdominal organs demonstrate a tiny calcified granuloma
 within the right lobe of the liver compatible with prior granulomatous
 disease, otherwise unremarkable. There is a small hiatal hernia.
                                                             (Over)

 [**2120-12-9**] 1:41 PM
 CT TRACHEA W/O C W/3D REND                                      Clip # [**Clip Number (Radiology) 72897**]
 Reason: EVAL TBM
 ______________________________________________________________________________


FINAL REPORT


(Cont)

 No osseous lesion to suggest malignancy or infection is identified.  Deformity
 of the right posterior fourth and fifth ribs are compatible with post-surgical
 changes related to recent tracheal bronchoplasty.


IMPRESSION:


1.  Significant improvement of tracheal bronchomalacia status post tracheal
 bronchoplasty as described above.

 2.  Multiple stable [**1-23**]-mm pulmonary nodules do not require followup.

 3.  Small hiatal hernia.


Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)
   Assessment:
   Pt with melana overnight, no further episodes of BRBPR, most recent hct
   30.2 up from 23.9 following the transfusion of 2 u PRBC, pt denies
   dizziness, denies abd pain, prepped with [**Last Name (un) **] tolerated prep well,
   NPO overnight, pt with frequent clear liquid stool overnight d/t prep
   as noted above, incontinent attempts with several incontinence bags,
   now with diaper, hemodynamically stable
   Action:
   Pt maintained NPO, q6hr hcts sent 00/06/12/18, continuing to monitor,
   GI in to assess
   Response:
   Pt with no further BRBPR overnight as noted above, bowel prep
   completed, hct stable following transfusion
   Plan:
   Pt to receive c-scope today, continue to monitor hct until stable,
   continue to monitor for BRBPR
   Hypotension (not Shock)
   Assessment:
   BP overnight 93-125/53-62
   Action:
   Pt received colloids as noted above for hct gtt
   Response:
   No periods of hypotension noted
   Plan:
   Continue to monitor hemodynamics
   Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)
   with Acute Exacerbation
   Assessment:
   Breath sounds dim throughout, pt on home levels of O2 4L NC, O2 sats
   96-99%, declined bipap overnight d/t frequent turning for incontinence
   Action:
   Maintaining on home levels of O2, offered bipap overnight, continuous
   O2 sat monitoring at this time, adm medications as ordered
   Response:
   Maintaining sats as noted above, COPD stable
   Plan:
   Continue on home O2 at this time, bipap on nights, meds as ordered


[**2189-12-1**] 9:32 AM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 67333**]
 Reason: please eval for infiltrate
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


39 year old woman with schizoaffective d/o with low grade temp


REASON FOR THIS EXAMINATION:


please eval for infiltrate
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


39-year-old female with schizoaffective disorder, now with
 temperature and white blood cell count.

 PA and lateral chest radiographs at 9:38 a.m.:

 Lung volumes are low, possibly due to poor inspiration.  Given this
 limitation, heart size is probably normal and apparent interstitial pulmonary
 abnormality at the lung bases may be artifactual.   No pleural effusion is
 present.  Hilar and mediastinal contours are normal.


IMPRESSION:


Repeat PA and lateral chest films were recommended.  The
 subsequent films at 10:57am taken at full inspiration, available at the time
 of dictation, show clear lungs.


Sinus rhythm. Normal ECG. No previous tracing available for comparison.


[**2193-1-17**] 10:53 AM
 CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST                      Clip # [**Clip Number (Radiology) 73267**]
 CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST
 Reason: R/o Malignancy
 Admitting Diagnosis: BRAIN LESION
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


49 year old man with large left parietal lesion


REASON FOR THIS EXAMINATION:


R/o Malignancy
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


49-year-old male with large left parietal lesion.  Rule out
 malignancy.


TECHNIQUE:


Contiguous axial CT images of the chest, abdomen, and pelvis were
 obtained with the administration IV contrast [**Doctor Last Name 1511**], 150 cc of Optiray.


FINDINGS:


Chest:  There is no evidence of significant mediastinal or hilar
 lymphadenopathy.  The heart is normal in size, and there is no evidence of
 pericardial or pleural effusion.  In the lung window, bilateral lungs are
 clear, and there is no evidence of suspicious mass or consolidation is seen.
 Note is made of non-calcified 2-mm nodule in the lingula.

 ABDOMEN:  The liver is unremarkable without evidence of focal liver lesion.
 Note is made of gallstone measuring 2 cm, without evidence of gallbladder
 dilatation.  Spleen, pancreas, adrenal glands and kidneys, the visualized
 portion of large and small intestines are within normal limits.  No
 significant lymphadenopathy.  No ascites.

 PELVIS:  The visualized portion of large and small intestines are within
 normal limits.  No ascites.  No significant lymphadenopathy.

 BONE WINDOWS:  There is no suspicious lytic or blastic lesion in skeletal
 structures.


IMPRESSION:


1.  Cholelithiasis.
 2.  Tiny 2-mm noncalcified pulmonary nodule in the lingula, please follow by
 CT scan in this patient with brain tumor.


[**2170-2-23**] 5:39 PM
 CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST                      Clip # [**Clip Number (Radiology) 54010**]
 CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST
 Reason: please define this patient's mass.  ? TB vs lymphoma?  Previ
 Field of view: 36 Contrast: OPTIRAY Amt: 130
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


52 year old man with right sided mass, tender, baseball sized, irregular
  borders, X 2 weeks


REASON FOR THIS EXAMINATION:


please define this patient's mass.  ? TB vs lymphoma?  Previously had MRI which
  revealed bulky right sided adenopathy
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: MGGb [**First Name9 (NamePattern2) 16**] [**2170-2-23**] 7:37 PM
  Interval increase in necrotic lesions involving the right paraspinal
  musculature and right paraspinal, subpleural region at the right lung base.
  Stable diffuse low density LN in mediastinum and abdomen, with innumerable low
  density lesions on the spleen and liver. This appearance is nonspecicif and
  could rpresent diffuse mycobacterial process, other atypical infectious
  process, or a malignancy (i.e lymphoma).

 ______________________________________________________________________________


FINAL REPORT


INDICATION:


52-year-old with AML and prior episode of disseminated TB,
 presenting with new right flank mass.  Evaluate for TB versus lymphoma.

 COMPARISONS:  CT torso of [**2169-11-14**].


TECHNIQUE:


Axial MDCT images through the chest, abdomen, and pelvis with 150
 cc of nonionic Optiray contrast.

 CT TORSO WITH IV CONTRAST:  There are multiple enlarged low-attenuation right
 paratracheal and paracardiac lymph nodes, stable from the prior CT. Persisting
 small pericardial effusion. There remains a 5mm well- circumscribed nodule in
 the anterior aspect of the right upper lobe, unchanged from prior studies. The
 remainder of the right lung appears clear. There is a very tiny [**Date Range 33400**]
 3-mm nodule at the posterior aspect of the left lower lobe, on series 2, image
 37, which was not definitively seen on the prior study.  No other nodules are
 seen throughout the left lung.  Increased in size from the prior CT, there is
 a large 5.6 x 4.7 thick walled, centrally necrotic right paraspinal,
 subpleural mass, at the level of the right lung base.  It is impossible to
 tell by CT whether this extends into the neural foramina at this level.  The
 adjacent ribs are not destroyed.

 CT ABDOMEN WITH IV CONTRAST:  Also increased in size compared to the prior
 study, there is a large peripherally enhancing centrally necrotic mass
 involving the right paraspinal muscles at the level of the inferior aspect of
 the liver. This correlates to the palpable mass on physical exam.  This was
 not present on the prior study as well.  Again demonstrated are innumerable
 hypodense ill- defined lesions in the liver, which appears slightly increased
 in size and number. There are innumerable splenic hypodense lesions, again
 also likely increased in size and number.  There are multiple large loculated
 cystic structures in the region of the porta hepatis, parapancreatic and
                                                             (Over)

 [**2170-2-23**] 5:39 PM
 CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST                      Clip # [**Clip Number (Radiology) 54010**]
 CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST
 Reason: please define this patient's mass.  ? TB vs lymphoma?  Previ
 Field of view: 36 Contrast: OPTIRAY Amt: 130
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 celiac access regions. These appear similar to the prior CT scan.  Probable
 simple cyst in the left kidney is unchanged.

 CT PELVIS WITH IV CONTRAST:  No abnormal lymphadenopathy is seen within the
 inguinal, deep pelvic, or iliac chain distributions.  The bladder is
 unremarkable.  The distal bowel appears normal.

 BONE WINDOWS:  No suspicious lytic or blastic lesions are seen throughout the
 visualized osseous structures.


IMPRESSION:


1) Significant increase in size in the two distinct necrotic masses involving
 the subpleural right paraspinal region and the paraspinal musculature on the
 right at the level of the right kidney.
 2) Stable low-density lymphadenopathy in the right paratracheal, paracardiac,
 portahepatus, and celiac access distributions.
 3) Perhaps slight increase in size and number of innumerable ill-defined
 hypodense lesions throughout the liver and spleen.
 4) Stable small pericardial effusion.
 5) Stable right upper lobe 5 mm pulmonary nodule, and tiny 2 mm left lower
 lobe pulmonary nodule.
 6) Stable probable simple left renal cyst.

 Per medical records, the patient has known disseminated mycobaterial
 infection, which appears to have progressed.  CT is suboptimal for evaluating
 for neural foraminal and intrathecal spread, and MRI of the spine would be
 more sensitive for this if there are neurologic symptoms.


RESP: PT. NOT TOLERATING VENT WEAN THIS AM. USING ALL ACCESSORY MUSCLES. TACHY AND HTN. LUNGS COARSE SOUNDING. SUCTIONED FREQUENTLY. PLACED BACK ON PS OF 10 WITH RESOLUTION OF SYMPTOMS. LUNGS NOW CLEAR. PT. COMFORTABLE.
GI; TOL TF'INGS WELL. GIVEN LACTULOSE AND INCONT. OF VERY LARGE AMT OF BROWN LOOSE STOOL. FIB APPLIED. NO STOOL SINCE THAT.
RENAL: PT. STILL VERY EDEMATOUS. GIVEN 20MG LASIX IVP WITH MODERATE DIURESIS. URINE WITH SEDIMENT.
ENDOC; K+ 3.5 AND GIVEN 40MEQ KCL VIA PEG. REPEAT K+ DONE AT 14PM. MG+ BEING REPLACED.
SEDATION: GIVEN 3MG MS IVP FOR AM CARE. TOL. WELL.
CV; PRESENTLY IN NSR-ST. ADEQUATE BP.
SKIN INTEGRITY: PENIS STILL OOZING.
NEURO: NOT RESPONSIVE.
SOCIAL: NO CALLS.
ID: LOW GRADE FEVER. CONTINUES ON ANTIBIOTICS.


63 yo woman present from home with SOB, CP, hypoxemia, O2 sat 72% on
   room air, 100% NRB applied O2 sat 100%.
   PMH: CAD, s/p MI [**11-8**], ESRD dialysis tu/th/sa, baseline dry weight
   54.2kg, CHF, PVD, s/p aortofem bypass, with numerous revisions, chronic
   mesenteric ischemia with known occlusion of [**Female First Name (un) 2712**], asthma,
   schizoaffective d/o, HTN, DM 2, DVT, lumbar disc disease,
   hyperlipidemia, GERD, gastritis, chronic pancreatitis, s/p ex lap for
   pancreas divisum with sphincterotomy, pelvic ovarian mass, s/p hyst &
   oorphrectomy, s/p choley, s/p right knee arthroscopy
   Pain control (acute pain, chronic pain)
   Assessment:
   Currently denies pain, staes takes Fentanyl patch and oxycodone in
   morning and evening at home, medicated with dilaudid in ED
   Action:
   Follow comfort level
   Response:
   Plan:
   Follow comfort level
   Renal failure, End stage (End stage renal disease, ESRD)
   Assessment:
   Admit weight 60.9, baseline dry wt 54.2 kg, dialysis started on arrival
   to MICU left arm fistula
   Action:
   HD today and tomorrow
   Response:
   Tolerating HD
   Plan:
   Follow weight, I/O, lytes
   Hypoxemia
   Assessment:
   Arrived on 100% NRB, o2 sat 100%, weaned to 4L n/c o2 sat 93-98%.
   Breath sounds with crackles at bases
   Action:
   Wean fio2 as sat tolerates
   Response:
   Tolerating wean from 100% NRB
   Plan:
   Wean fio2 to sat after dialysis


CSRU NURSING TRANSFER NOTE:

PT WITH KNOWN RHEUMATIC HEART DISEASE AND RECENT SOB.  RECENT CHF BY CXR.  ETT SHOWED REVERSIBE DEFECTS.  REFERRED TO [**Hospital1 53**] FOR CARDIAC CATH.

CATH SHOWED 3V CAD AND 3+MR.

[**1-11**]:  CABGX3:  LIMA->LAD, SVG->RCA, OM1.  DEFIB X4 COMING OFF PUMP.  VERY OOZY POST-OP, DID REQUIRE NEO AND MULTIPLE FLUID BOLUSES.  SETTLED OUT.

NEURO:  PT ALERT AND ORIENTED.  FOLLOWS COMMANDS, MAE.

CV:  PT DENIES CP, PALP, SOB.  TELE:  MP SB/NSR.  HR 50-60'S.  HR DROPS TO 50'S AFTER LOPRESSOR.  A WIRES FAILING TO SENSE APPROPRIATELY, BUT V WIRES WORK PROPERLY.  PACER SET AT VVI AT 45 BPM.

RESP:  LS CTA.  PT HAS STRONG NPC.  CT D/C'D TODAY.

GI:  ABD SOFT, NONTENDER, +BS, NO BM.  PT [**Name (NI) 452**] ZANTAC.  APPETITE IMPROVING.

GU:  FOLEY INTACT.  UOP ADEQUATE, THOUGH NO SIGN RESPONSE FROM LASIX.

PAIN:  PT DENIES PAIN.

ACTIVITY:  PT AMBULATING AROUND UNIT WITH ASSIST.

PLAN:  TX TO [**Hospital Ward Name **] 6.  CONTINUE TO MONITOR.  INCREASE ACTIVITY AS TOLERATED.


84 y M w/ SBO not resolving with conservative therapy.   s/p ex-lap
   [**10-31**].  Transferred from PACU to TSICU for further management.
   Post-operative hypotension/SIRS.  t
   PMHx:
   PMHx: A fib, HTN, DM, Duodenal ulcer, spinal stenosis,? Crohn
   disease, kidney stones, CKD, BPH, onychomycosis, rosacia
   [**Doctor First Name **] Hx: sigmoidectomy and two additional abdominal surgeries for SBO,
   L TKR, numerous back surgeries
   Meds: amiodarone 100 mg qday, Lasix 20 mg qday, Combivent 2 puffs q6hrs
   prn, Metoprolol Succinate 75 mg qday, Simvastatin 80 mg qday, Coumadin
   3 mg QSun,mon,[**Last Name (un) **],fri , Coumadin 4 mg q T/Th/Sat, Tylenol prn, aspirin
   81 mg qday, Calcium Citrate-Vitamin D, Insulin Novolin SS and lantus,
   Sulfasalazine
   Days events:
   Levophed weaned off
   Tolerating Fentanyl/propofol weaning
   Slight improvement noted in mental status.
   Pain control (acute pain, chronic pain)
   Assessment:
   Pt able to nod/shake head yes/no to simple questions inconsistently.
   Pt  more alert this am, shaking his head no to inquiries of pain.
   Extremities rigid at times.
   Action:
   Fentanyl gtt weaned to 150mcg/hr.  Propofol gtt weaned to 10mcg/kg/min.
   Dilaudid 1mg q4hrs intitiated.
   Response:
   Tolerating turning/care well without facial grimaces without fentanyl
   boluses.
   Arousable to voice or gentle stimulation, following more commands
   inconsistently.
   Plan:
   Cont. to monitor pain, administer dilaudid 1mg q4hrs, wean fentanyl gtt
   as tolerated.
   .H/O small bowel obstruction (Intestinal obstruction, SBO, including
   intussusception, adhesions)
   Assessment:
   Abd obese, distended, BS very hypoactive.
    No BM or flatus noted.
   NGT to LCWS sxn with sm. Amt. bilious drainage output.
   Action:
   NG suction maintained.
   Remains NPO.  Pepcid for prophylaxis.
   Response:
   NG conts. sm. Amt. bilous drainage.
   Plan:
   Monitor GI fxn, cont. NGT to sxn.
   Pepcid as ordered.
   SIRS
   Assessment:
   Conts. Low grade temps. 99.5po
   In/out of afib while on amio gtt
   Levophed gtt titrated off approx. 0720 this am
   CI trending [**2-21**], SVV remains <10 (when pt is in SR)
   Adquate uo.  IVF KVO.
   Action:
   Conts. Flagyl/vanco/zosyn
   10mg diltiazem IV x1 for rate control.
   10mg IV lasix x1.
   Response:
   Returned to SR after diltiazem x1, however, conts. to flip back and
   forth SB/SR->afib currently.
   Currently diuresing from lasix.
   Plan:
   Vigileo to remain in place until approx. 24hours after pressors off.
   Cont. abx as ordered, follow cultures/labs.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   Remains on SIMV 600x15/10PS/10 PEEP/50% since am rounds.
   No breaths over vent settings observed.
   LS clear, diminished at bases with scant to minimal secretions.
   Action:
   Conts. pulmonary hygiene.
   VAP care per protocol.
   Response:
   Tol. Current vent settings and care on decreased sedation.
   Plan:
   Monitor resp. status, cont. pulmonary hygiene, VAP care.
   Wean vent when able as sedation is lightened.


[**2146-12-31**] 4:50 PM
 CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN                 [**Name Initial (PRE) 7**] # [**Clip Number (Radiology) 71974**]
 Reason: int changes, CT in place, eval for PTX
 Admitting Diagnosis: TRACHEBRONCHIALMALACIA/SDA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


52 year old woman with tracheoplasty


REASON FOR THIS EXAMINATION:


int changes, CT in place, eval for PTX
 ______________________________________________________________________________
 WET READ: AGLc SAT [**2146-12-31**] 11:33 PM
  no change from 10 hrs prior, including RUL opacity, which were more discrete
  on [**2146-11-19**].  no ptx seen.
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Chest tube in place, to evaluate for pneumothorax.


FINDINGS:


In comparison with earlier study of this date, there is little
 change.  Chest tubes remain in place without definite pneumothorax.  Patchy
 area of increased opacification persists in the right upper zone.  There is
 continued enlargement of the cardiac silhouette with evidence of elevated
 pulmonary venous pressure.


NPN 0700-1900


1. Resp: Infant remains in RA, RR 30-60's, lung sounds
clear/= with no retractions noted. Infant has had no A's/B's
thus far this shift. P:Continue to monitor resp.

2. Fen: TF 150cc/kg/day of BM28 with bp/SC28=48cc q4hrs.
Infant bottled x1 this shift with mom and took 15cc with
good coordination but tired easily. Tolerating feeds
well;abd exam benign, no spits minimal asp. Infant is
voiding and has had no stool thus far this shift. Continues
on Iron & Vit E. P:Continue to support nutritional needs and
work on po feeds.

3. [** **]: Mom in for the day and updated regarding infants
condition and plan of care. Mom invested, [**Name2 (NI) **] with
cares. Appears to be stressed regarding #1's spells &
possibility of #3 going home in the near future. P:Continue
to update and support.

4. G/D: Temps remain stable cobedding in an [**Name2 (NI) **]. Infant has
not been waking for cares, is quietly [**Name2 (NI) **] during cares and
has been sleeping well inbetween. AFSF. MAE. P:Continue to
support developmental needs.


[**2185-7-6**] 7:26 PM
 UNILAT UP EXT VEINS US                                          Clip # [**Clip Number (Radiology) 63917**]
 Reason: swollen rt arm s/p picc line removal r/o dvt
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


48 year old woman with ?dvt rt arm


REASON FOR THIS EXAMINATION:


swollen rt arm s/p picc line removal r/o dvt
 ______________________________________________________________________________
 WET READ: ESE WED [**2185-7-6**] 9:08 PM
  Thrombus in the distal brachial vein.  Low flow in the basilic vein.

 ______________________________________________________________________________


FINAL REPORT


CLINICAL INDICATION:


Swollen right arm, status post PICC line removal, please
 assess for DVT.

 RIGHT UPPER EXTREMITY VENOUS DUPLEX ULTRASOUND:

 The right internal jugular vein was not well visualized secondary to the
 patient's body habitus and tracheostomy tube.  Color flow and augmentation are
 demonstrated in the right subclavian and right axillary vein.  Normal flow and
 compressibility is demonstrated in the right cephalic vein.  The basilic vein
 reveals very slow flow, but is compressible.  No compressibility and no flow
 is demonstrated in the distal branch of the right brachial vein.


IMPRESSION:


Thrombus within the distal right brachial vein.


Respiratory Care
Plan: abdominal CT today


Objective
   Pertinent medications: Versed drip, Fentanyl drip, Lasix drip,
   Norepinephrine drip, Flagyl, Heparin, Pantoprazole, vitamin B12,
   multi-vitamin
   Labs:
   Value
   Date
   Glucose
   117 mg/dL
   [**2130-4-18**] 03:47 AM
   Glucose Finger Stick
   174
   [**2130-4-18**] 12:00 PM
   BUN
   41 mg/dL
   [**2130-4-18**] 03:47 AM
   Creatinine
   0.9 mg/dL
   [**2130-4-18**] 03:47 AM
   Sodium
   137 mEq/L
   [**2130-4-18**] 03:47 AM
   Potassium
   4.4 mEq/L
   [**2130-4-18**] 03:47 AM
   Chloride
   98 mEq/L
   [**2130-4-18**] 03:47 AM
   TCO2
   32 mEq/L
   [**2130-4-18**] 03:47 AM
   PO2 (arterial)
   95.[**Numeric Identifier 252**] mm Hg
   [**2130-4-18**] 08:24 AM
   PO2 (venous)
   69 mm Hg
   [**2130-4-15**] 04:51 AM
   PCO2 (arterial)
   45 mm Hg
   [**2130-4-18**] 08:24 AM
   PCO2 (venous)
   56 mm Hg
   [**2130-4-15**] 04:51 AM
   pH (arterial)
   7.46 units
   [**2130-4-18**] 08:24 AM
   pH (venous)
   7.37 units
   [**2130-4-15**] 04:51 AM
   pH (urine)
   5.0 units
   [**2130-4-18**] 04:37 AM
   CO2 (Calc) arterial
   33 mEq/L
   [**2130-4-18**] 08:24 AM
   CO2 (Calc) venous
   34 mEq/L
   [**2130-4-15**] 04:51 AM
   Albumin
   1.7 g/dL
   [**2130-4-15**] 03:54 AM
   Calcium non-ionized
   7.0 mg/dL
   [**2130-4-18**] 03:47 AM
   Phosphorus
   2.7 mg/dL
   [**2130-4-18**] 03:47 AM
   Ionized Calcium
   1.10 mmol/L
   [**2130-4-16**] 03:11 AM
   Magnesium
   2.2 mg/dL
   [**2130-4-18**] 03:47 AM
   ALT
   84 IU/L
   [**2130-4-18**] 03:47 AM
   Alkaline Phosphate
   138 IU/L
   [**2130-4-18**] 03:47 AM
   AST
   53 IU/L
   [**2130-4-18**] 03:47 AM
   Amylase
   68 IU/L
   [**2130-4-14**] 04:19 PM
   Total Bilirubin
   2.5 mg/dL
   [**2130-4-18**] 06:00 AM
   WBC
   13.1 K/uL
   [**2130-4-18**] 03:47 AM
   Hgb
   10.0 g/dL
   [**2130-4-18**] 03:47 AM
   Hematocrit
   31.7 %
   [**2130-4-18**] 03:47 AM
   Current diet order / nutrition support: Diet: NPO
   Tube feed: OFF (Isosource 1.5 @ 45ml/hr + 14g Beneprotein =
   1670calories and 85g protein)
   GI: soft/distended, positive bowel sounds, loose stool
   Assessment of Nutritional Status
   Specifics:
   Remains intubated/sedated.  s/p family meeting [**4-17**], family decided to
   go ahead with tracheostomy and PEG.  Tube feed has been running at goal
   via OGT, patient tolerating with minimal residuals until off since noon
   for CT torso.  Also, plan for valvuloplasty tomorrow (tube feed to be
   stopped again at midnight).  Wound care RN following
 skin breakdown
   on left Achilles and unstageable on coccyx.  s/p bedside debridement by
   plastic surgery [**4-17**].  Lactulose/Colace given [**4-17**]
 loose stool today.
   Medical Nutrition Therapy Plan - Recommend the Following
          Multivitamin / Mineral supplement: continue tube feed at
   goal
          Tube feeding recommendations:
   o         Resume tube feed when able post procedures
          Check residuals, hold tube feed if greater than 200ml
          Monitor abdominal exam
          Monitor skin integrity
          Check chemistry 10 panel
   Will follow, page if questions *[**Numeric Identifier 606**]
   [**2130-4-18**] 15:49


RN-19:00 to 23:00
   Hypertension, benign
   Assessment:
   BP in 140-150
s systolic at times. HR 80-100 SR with occasional
   PAC/PVC
s. Calm but does hold your hand for comfort. VS improves when
   sleeping. CPAP 5/5. Denies pain. Follows command but still lethatgic.
   Action:
   Lopressor 10 mg every 4 hrs with po Lopressor. Hydralazine 10 mg IV x1
   dose.
   Response:
   BP 130-140 after Lopressor.
   Plan:
   Goal BP<140 syst. CPAP 5/5. Adjust PSV for comfort overnight.
   Diabetes Mellitus (DM), Type I
   Assessment:
   Insulin drip @ 2 units/hr. Type 1 diabetes.
   Action:


[**2143-5-24**] 11:05 PM
 ESOPHAGUS                                                       Clip # [**Clip Number (Radiology) 91373**]
 Reason: gastrograffin, then thin barium swallow to assess for esopha
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


83 year old woman with esophageal tear


REASON FOR THIS EXAMINATION:


gastrograffin, then thin barium swallow to assess for esophageal perforation in
  known mucosal tear
 ______________________________________________________________________________


FINAL REPORT


CLINICAL INDICATION:


83 year old female with esophageal tear. Assess for
 perforation.


TECHNIQUE:


Gastrografin and barium esophagogram.


COMPARISON:


None.


FINDINGS:


Gastrografin was initially administered to the patient, followed by
 thin barium. There was no evidence of an esophageal leak. The esophagus
 is normal caliber throughout. No significant mucosal abnormalities are
 detected. Contrast passed freely to the stomach.


IMPRESSION:


No evidence of esophageal perforation.


CONTINUATION OF ABOVE NOTE
GI:  ABDOMIN SOFT, + BOWEL SOUNDS.  PASSING MODERATE AMTS OF LIQUIDY OB NEG BROWN STOOL---RECTAL BAG PLACED.  CHANGED THE TUBE FEEDING TO PEPTAMEN FROM CRITICAL HN AND THIS IS INFUSING AT 60CC/HR VIA THE PEG--NO RESIDUALS OBTAINED.  DID COMPLAIN OF NAUSEA, WHICH RESOLVED WITHOUT INTERVENTION.

GU:  FOLEY IN PLACE.  URINE OUTPUT APPROX 60-75CC/HR.  BUN 13 AND CREAT .6.  GIVEN 20MG OF LASIX AT 6:10P.  INCONTINENT OF URINE AROUND CATHETER ONCE.


NURSING PROGRESS NOTE:

SEE CAREVUE FOR EXACT DATA

NEURO-Pt. more alert throughout shift. Speech somewhat garbled, however able to state name and year. Unsure of place and month. Pleasantly confused (singing/talking to self). Continues to have difficulty tracking. Pupils 4 and briskly reactive, MAE's. Follows commands at times.

CV-SR 80-90's with frequent PVC's/APC's. SBP 110-130/50-60's MAP 70's. Lopressor 10mgIV q4hours. Left SC TLC with CVP ranging [**6-7**]. Compression boots and heparin. HCT stable at 29.1

RESP-Extubated [**2-10**] at about 1200. Humidified face tent on 50%FIO2, tolerating brief periods off O2. Deep suctioned for thick white secretions. Pt with strong productive cough. Lung sounds clear to coarse at times.

GI-Post pyloric feeding tube with tube feeds at goal (100cc) Impact 3/4strength. NGT to LCWS with green bilious drainage. Abdomen soft, present bowel sounds. Muchroom cath with golden liquid stool. Protonix.

GU-20mg lasix given at beginning of shift. Goal 3L negative daily, yesterday negative 2L, presently negative 600cc. Indwelling foley catheter with clear yellow urine output. AM lytes WNL. BUN rising.

ENDO-Continues on [**Last Name (un) 296**] ISS. Insulin at 2-6units throughout shift.

ID-Tmax 99.6. Meropenum and Fluconazole as ordered.

SKIN-Fungal rash to groin, bilateral UE's and truck clearing. Miconazole cream to rash.

PLAN-Continue with pulmonary toileting, [**Last Name (un) 122**] O2 as tolerated.
    -Monitor UOP, fluid status.
    -Titrate insulin gtt [**First Name8 (NamePattern2) 20**] [**Last Name (un) 296**] sliding scale.
    -Antibiotics as ordered.


T/SICU NPN: 0700-1900
S: "Do you think I'll be able to work on Monday?"

O:  System Review:

Neuro:  awake, alert and oriented x 3  calm and appropiate manner
speech normal  conversation appropiate  at times, looses train of thought and has difficulty with recall--asking same questions(particularly in morning)  PERRL 3-4mm  brisk reaction
left eye with ++blood in outer corner  intermittently c/o blurry/double vision  intact cough/gag  MAE to command  movement restricted with UE d/t injuries  c-collar remains on  c/o neck pain  neck MRI at 1100 to r/o ligament injury  awaiting final read from radiologist  follow-up head ct at 1530(12hrs after admission head ct)
head ct with new finding--SDH  Neuro resident in to assess neuro status  continues on dilantin 100mg q8hrs  c/o headache  intitially frontal, but now c/o back of head hurts also  rates HA pain score "5"
and "tolerable"  TLS cleared  logroll precautions d/c

CVS:  HR: 70-90's  NSR  no ectopy  SBP 80-90's with MAP mid 50's to 60's  pt reports that BP runs on low side--SBP ~90   palpable pedal
pulses

Respiratory:  RR 16-24  Sao2 > 96% on room air  lungs clear  fair non-productive cough  encouraging DB's  started IS--moving up to 750cc

Renal:  foley patent and draining clear light yellow>>yellow urine
urine slowing down 360cc/hr>>>30-100cc/hr  K+ 3.5  repleted with 40meq KCL in 500cc over 6hrs  repeat K+ pnd  also, MG++/Ca++ pnd
NS with 20meq KCL at 100cc/hr(held with K+ repletion infusion)

GI:  abdomen: flat soft  hypoactive bs  remains NPO on IVF  on pepcid
c/o nausea x 1--transient and short-lived

Endocrine:  FS q6hrs  FS 90-100's  no insulin required

Heme:  HCT 30.7  PLT 173  INR 1.3  continues on pneumoboots

ID:  tmax 100.1  WBC 9.2  on no antibiotics

Skin:  back and buttocks intact with no redness  Plastics in this AM
hands(knuckles)cleansed with betadine scub and irrigated with NS
two lacerations on left hand sutured  all covered with xeroform/dsd
draining small to moderate amounts of serosanguinous fluid from wounds
hand splints ordered  OT up and fitted pt with splints  splints on and arms elevated  fingers swollen and discolored--ecchymotic  palms with ecchymosis also  small abrasion on left elbow--cleansed with NS, covered with xeroform and dsd

Comfort:  consistently c/o pain in arms shoulders>>>hands  pain scores
[**7-12**]  medicated x 2 with 25mcg fentanyl iv with less pain----dozing off
SBP drifts in low to mid 80's after fentanyl dose

Psychosocial:  many family and friends in all day  pt "ok" with all the visitors  updated on clinical situation and questions answered

A:  new SDH  neuro exam unchanged

P:  continue to monitor above parameters  neuro exams q2hrs  Head CT's
as ordered  await results of neck MRI  pain management


[**Location (un) 215**]/NEON DOL 13 CGA 31 [**1-19**]
RA, no A&B's for 48 hours, on caffeine, RR 40-60's, HR 130-150
Wt 1075 up 20 on MM28Pro ( 150 cc/kg/d)
On Vit E, Fe,
HUS scheduled, to be done sometime this week. Being bumped because of acuity of other patients.
Spoke with mom, she will be visiting [**Hospital3 **] this week.


This is an 86 year old female with a hx of RA, HTN, hyperlipidemia, and
   symptomatic AS who initially presented for elective valvuloplasty, now
   s/p ruptured right groin pseudoaneurysm and repair. # .
   . HCT improved 10 points with 4 units, a relatively appropriate bump.
   laryngeal edema after multiple intubation attempts,required
   traheostomy. Received long acting paralytics during the procedure
   requiring longer term ventilation
   Dilated stomach: Likely from extended ambu-bagging. Unable to pass
   NG/OGT. Will likely resolve on own.
   .
   .
   Aortic stenosis
   Assessment:
   Hr 100-[**Known lastname **] with no vea.  Bp 80-100
s/  Also noted CHB with
   vomiting.   C/O pain in neck area, throwing leg over the side rail.
   Action:
   rec
d small fent bolus (25mcg) and versed started for  c/o pain  with
   decrease in bp to 60
s. For elevated hr in the 130-140
s  given total
   of 15mg iv lopressor and 1 liter NS bolus.
   Response:
   Gradual decrease in hr to 90
s with bp in 90-100
s.  All sedation on
   hold for now.
   Plan:
   Follow hr, ? further lopressor if hr increases again.  Follow for heart
   block with emesis
   .H/O hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD
   bleed)
   Assessment:
   R groin with large eccymotic area.  Dressing with bloody drng, noted to
   cont to have small amt of ooze from site.  Distal pulses
   palpable/dopplerable.  R leg larger than left
   Action:
   Hct checked
   Response:
   Hct stable at 34.
   Plan:
   Recheck hct this am, follow pulses.
   .H/O laryngeal edema
   Assessment:
   Trach sutured in place.  + ooze from around site.  Also has large amt
   of eccymosis in neck area extending to back.  Area is outlined.
   Remains on vent support.  ABG good.  Lungs with crackles approx [**2-5**]
   dependantly, also tubular aeration heard in LLL.  Sats have remained in
   99-100% range.  Suctioned for scant amts of blood tinged secretions.
   Action:
   Decreased fio2 to 40%.  Frequent mouth care, requesting and rec
ing ice
   chips
   Response:
   Good oxygenation .  tolerating po ice chips without problem, at times
   having [**Last Name (LF) 11082**], [**Name8 (MD) **] md this is normal occurrence for her.
   Plan:
   Cont to follow oxygenation.  Maintain airway.
   .H/O fever, unknown origin (FUO, Hyperthermia, Pyrexia)
   Assessment:
   Temp 102.5po as max, decreasing to 99.7
   Action:
   Given tylenol pr, conts on iv antibx
   Response:
   Febrile possibly from general anesthesia vs infection
   Plan:
   Monitor fever, cont with tylenol, follow cultures.


81 yo W with PMH of CAD, CHF, ESRD on HD, AVR on coumadin presents with
   trochanteric fracture and hypotension.
   .
   Hypotension (not Shock)
   Assessment:
   Sbp this am >100.  Hct stable at 37.3.
   Action:
   Bp meds held this am in preparation for hd.
   Response:
   Sbp did dip into the low 80
s on hd. Goal for fluid removal cut back to
   1l.
   Plan:
   Cont to monitor bp.
   Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney
   disease)
   Assessment:
   K up to 5.6 this am.
   Action:
   Hd done in micu today.
   Response:
   Plan:
   Review of systems
   Neuro- alert and oriented x3 and cooperative with care.
   Resp- on 2l nc which is what she wears at home. Bs clear. Resp teens to
   low 20
s.  Given IS to use to encourage deep breaths. Cardiac- hr high
   40
s to low 50
s sb. Sbp low 100
s. with sleep last night sbp down to
   80
s. No increase in bp with fluid boluses. Team feels her baseline is
   80-90.
   Gi- abd soft with pos bs. Has transverse [** 10253**] that is putting out
   brown soft stool that is guiac neg. [** 10253**] appliance last changed on
   Monday. Change 2 times a week or prn. Supplies with patient. Se note by
   wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 10253**] care.
   Gu/renal- voids about once per week. Hd 3x week. Mon- wed- fri.
   Skin- sk8in dry. Has callus on left great toe that is pink without


Resp Care
Pt remains on vent. No changes made. Sucitoned small amt of blood tinged secretions. Tobra neb given. Sating in the high 90s. Will continue to monitor.


[**2117-9-13**] 9:45 AM
 G/GJ TUBE CHECK                                                 Clip # [**Clip Number (Radiology) 31369**]
 Reason: Needs gastrografin injected in PEG followed by prone abd [**Last Name (un) **]
 Admitting Diagnosis: ABDOMINAL PAIN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


76 year old woman with persistent free air with PEG placed 11 days ago.
  Needs gastrografin injected in PEG followed by prone abd film to assess for
  leak followed by upright film to assess whether contrast tracks down to pelvis.


REASON FOR THIS EXAMINATION:


Needs gastrografin injected in PEG followed by prone abd film to assess for
  leak followed by upright film to assess whether contrast tracks down to pelvis.

 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Persistent free air with PEG placed eleven days ago.


COMPARISON:


[**2117-9-12**].

 SUPINE FILMS, PRE- AND POST-WATER SOLUBLE CONTRAST INJECTION:  The initial
 supine film demonstrates residual contrast within the area of the splenic
 flexure and through the descending colon and rectum.  Gastrostomy tube is
 noted in the left side of the abdomen.  Under fluoroscopic guidance,
 approximately 60 cc of water soluble contrast was injected into the stomach.
 The patient was turned into the left lateral position, and contrast remained
 within the stomach.  A second overhead film of the patient in the supine
 position shows the newly injected contrast to remain within the stomach. There
 is no evidence of leak. There is a fair amount of free air noted on the supine
 film, that is likely slightly decreased from yesterday.  The patient was not
 turned into the upright position.


IMPRESSION:


No evidence of leakage of contrast from the stomach status post
 contrast injection through gastrostomy tube.


[**2111-12-29**] 5:15 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 46172**]
 Reason: Effusion, PNA
 Admitting Diagnosis: N/V
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


50 year old woman with dCHF, aflutter, had a flash pulmonary edema.


REASON FOR THIS EXAMINATION:


Effusion, PNA
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Congestive failure with flash pulmonary edema.


FINDINGS:


In comparison with the study of [**12-28**], there has been substantial
 decrease in the diffuse pulmonary opacifications consistent with pulmonary
 edema.  No definite infiltrate is appreciated on this somewhat lordotic view.


Neonatology Attending Note
Day 8, PMA 32 3

RA. RR40-60s. Caff. No murmur. HR 140-160s. BP 84/33, 53.
Reb [** **] 7.6/0.3.
Wt 1770, up 25 gms. TF 150 = 125 BM20/PE20 + 25 IVF (D10w [**2-4**]). Tol well. Voiding and stooling.
Isolette.

A/P:
Growing preterm infant with resolv RDS, resolv hyperbili, adv feedings. Will cont to adv enteral nutrition. Cont to monitor.


Atrial fibrillation, mean ventricular rate 58. Compared to the previous tracing
of [**2134-7-12**] multiple abnormalities as previously noted persist without major
change.


[**2160-12-5**] 4:51 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 74710**]
 Reason: assess R thoracic cavity, CT position
 Admitting Diagnosis: PNEMONIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


65 year old woman s/p completion R pneumonectomy


REASON FOR THIS EXAMINATION:


assess R thoracic cavity, CT position
 ______________________________________________________________________________
 WET READ: JRCi [**Name2 (NI) 340**] [**2160-12-5**] 6:11 PM
  S/P completion right pneumonectomy with new apical chest tube and aerated
  right hemithorax. Small amount of free intraperitoneal air. Left lung remains
  clear aside from small left apical pneumothorax.  Right chest wall
  subcutaneous emphysema. Endotracheal tube cuff is mildly hyperinflated. Lines
  and tubes otherwise standard position.
 ______________________________________________________________________________


FINAL REPORT


CLINICAL HISTORY:


Status post completion right pneumonectomy, assess position
 of GT tube.

 The position of the endotracheal tube is satisfactory.  A right chest tube is
 present within a large pneumothorax with almost complete collapse of the
 remaining right lung.  Free air under the right hemidiaphragm is present also.
 I doubt the presence of a left pneumothorax despite the initial report.  The
 linear density outlined extends beyond the confines of the chest.


IMPRESSION:


Left lung clear.


NEURO  ALERT ORIENTED BUT LETHARGIC MOVES ALL EXTREMETIES GENERALIZED WEAKNESS

C/V  AFIB FREQ TO OCC PVCS HR 80-90S B/P STABLE 90S AFTER LASIX AND UP IN CHAIR GOOD PEDAL PULSES

RESP  NC 3L SATS 100% NONPRODUCTIVE LUNGS CLEAR CHEST TUBE DRAINING PINK TINGED

GU/GI  TOL TF WELL ABD SOFT BOWEL SOUNDS HEARD SMALL LOOSE STOOL MUSHROOM CATH IN PLACE ADEQUATE URINE OUT GOOD RESPONSE TO LASIX AFTER ALBUMIN URINE BECOMES BLOODY WITH ANY MANIPULATION OF FOLEY CLEARS WITH TIME

ACTIVITY  OOB TO CHAIR 2 ASSIST POOR WGHT BEARING ATTEMPT TO WALK WITH DIFFICULY TODAY

PLAN  CONTINUE TO MONITOR MENTAL STATUS  REATTEMPT AMBULATION IN AM


[**2153-2-14**] 6:26 PM
 CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY                    Clip # [**Clip Number (Radiology) 87150**]
 CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY
 CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY
 Reason: eval for acute process
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


51 year old man with hep C, abd pain, ? infarcts on OSH CT


REASON FOR THIS EXAMINATION:


eval for acute process
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: JKSd WED [**2153-2-14**] 8:00 PM
  Multiple small peripheral lung nodules and areas of wedge-shaped
  hypoenhancement in the kidneys bilaterally.  Marked splenomegaly with areas of
  decreased perfusion. Constellation of findings is concerning for septic emboli
  and infarcts of kidneys and spleen.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


51-year-old man with hepatitis C, abdominal pain and question
 infarcts on outside hospital CT.  Evaluate for acute process.  Please note
 that this CT examination is being submitted for a second read request.


TECHNIQUE:


The study was acquired at an outside hospital and transferred with
 the patient to [**Hospital1 184**].  The referring physician here requests [**Name Initial (PRE) **] second opinion
 interpretation.


COMPARISON:


None.


FINDINGS:


CT OF THE CHEST WITH CONTRAST: Evaluation is limited due to the respiratory
 motion throughout the entire exam. Evaluation for pulmonary embolism is
 especially limited given motion and timing of contrast bolus. However, there
 are no large main pulmonary artery pulmonary embolisms.

 Multiple small pulmonary nodules are noted bilaterally in a far peripheral
 distribution measuring up to 9 x 5 mm (4:92).  There is no pneumothorax or
 focal areas of consolidation.  The heart size is normal.  There is no
 pericardial effusion.  There is no hilar, mediastinal or axillary
 lymphadenopathy.  There is no aortic dissection.  Gynecomastia is present.

 CT OF THE ABDOMEN WITH IV CONTRAST:  The spleen is massively enlarged.
 Multiple areas of wedge-shaped hypoattenuated defects are present, most
 consistent with multiple splenic infarcts.  Similarly, the kidneys bilaterally
 also demonstrate multiple peripheral wedge-shaped areas of hypoattneuation.

 The adrenal glands, pancreas, liver, and gallbladder are unremarkable.  The
 intra-abdominal loops of small bowel are collapsed.  There is no free air or
 free fluid.  There is no retroperitoneal or mesenteric lymphadenopathy.

 CT OF THE PELVIS WITH IV CONTRAST:  A Foley catheter is noted within a
 decompressed bladder.  The prostate and rectum are within normal limits.
                                                             (Over)

 [**2153-2-14**] 6:26 PM
 CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY                    Clip # [**Clip Number (Radiology) 87150**]
 CT ABDOMEN W/CONTRAST; OUTSIDE FILMS READ ONLY
 CT PELVIS W/CONTRAST; OUTSIDE FILMS READ ONLY
 Reason: eval for acute process
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 There is apparent bowel wall thickening of the colon, from cecum to sigmoid
 colon.   A small amount of free fluid is noted within the pelvis.  There is no
 pelvic or inguinal lymphadenopathy.  The arterial vasculature appears normal
 without evidence of vasculopathy.  Although evaluation is limited as this is
 not an arterially timed phase and there is significant motion artifact, no
 occlusion is noted within the visualized abdominal and pelvic vasculature.

 BONE WINDOWS:  Degenerative changes are noted throughout the visualized spine,
 most prominent at L5-S1.  Mild anterior loss of height of T11 and T12 of
 unknown chronicity.


IMPRESSION:


1.  Multiple, small, peripheral nodules within the lungs.  Given appearance
 and distribution of these nodules, diagnostic consideration favors septic
 emboli.

 2.  Multiple areas of wedge-shaped hypoenhancement within the kidneys
 bilaterally and throughout the markedly enlarged spleen.  These findings are
 concerning for infarcts in the kidneys bilaterally and spleen.

 3.  Given findings in items number 1 and 2, septic emboli causing infarcts is
 a possibility.  Further evaluation for a right to left cardiac shunt with
 echocardiography is recommended.

 4.  Thickening of the ascending colonic wall, concerning for an infectious or
 ischemic process.


[**2182-7-11**] 4:23 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 17554**]
 Reason: Pt. s/p placement left subclavian vein double lumen hickman
 Admitting Diagnosis: ACUTE LEUKEMIA;NEUTROPENIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


68 year old woman with see above.


REASON FOR THIS EXAMINATION:


Pt. s/p placement left subclavian vein double lumen hickman catheter. Please
  evaluate location/ ? ptx.
 ______________________________________________________________________________


FINAL REPORT


CHEST AP PORTABLE SINGLE VIEW


INDICATION:


S/P placement of left subclavian vein double lumen Hickman
 catheter.  Evaluate position.


FINDINGS:


AP single view of the chest demonstrates now the placement of a
 wide caliber central venous line using the left subclavian approach.  The line
 tip is overlying the SVC terminating 2 cm below the level of the carina.  Thus
 position is as desired and there is no evidence of any pneumothorax or any
 other placement related complication.  Pulmonary vasculature remains unchanged
 and is within normal limits.  No new abnormalities in comparison with the next
 previous examination of [**2182-7-10**] at which time no acute infiltrates or CHF
 was identified.  A relatively low position and flattened diaphragm again are
 suggestive of COPD.


[**2128-11-4**] 6:10 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 10055**]
 Reason: ETT placement
 Admitting Diagnosis: UPPER GI BLEED
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41 year old man with etoh intoxication and reintubation


REASON FOR THIS EXAMINATION:


ETT placement
 ______________________________________________________________________________
 WET READ: [**First Name9 (NamePattern2) 4212**] [**Doctor First Name 141**] [**2128-11-4**] 6:41 PM
  ETT is at the level of clavicular heads. NG tube is not seen.  Interval
  worsening of bilateral perihilar opacities, left greater than right, likely
  representing aspiration pneumonia. Small left pleural effusion has increased
  in size.
 ______________________________________________________________________________


FINAL REPORT


AP CHEST 5:59 P.M., [**11-4**]


HISTORY:


Reintubated.  Check ET tube placement.


IMPRESSION:


AP chest compared to [**11-1**] and 7:

 New consolidation in the already consolidated left lower lobe accompanied by
 more leftward mediastinal shift indicates development of worsened atelectasis
 in addition to  widespread pneumonia which is worsening and also in the left
 upper and right lower lungs zones.  Heart size is normal.  Pleural effusion is
 small, probably bilateral.  Heart is normal size.  ET tube tip is at the
 thoracic inlet in standard placement and a right subclavian line tip projects
 over the SVC.  No pneumothorax.


[**2108-12-20**] 12:42 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 58413**]
 Reason: Please evaluate for intracranial bleed.
 Admitting Diagnosis: HEP C, CIRRHOSIS
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


50 year old man with end stage liver disease, coagulopathy s/p fall, hit his
  head no loss of consciousness.


REASON FOR THIS EXAMINATION:


Please evaluate for intracranial bleed.
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


50-year-old man with end-stage liver disease and coagulopathy
 status post head trauma.  No loss of consciousness.


TECHNIQUE:


Non-contrast head CT.


COMPARISON:


[**2108-12-15**].


FINDINGS:


There is no intracranial hemorrhage, abnormal extra-axial fluid
 collection, mass effect or midline shift.  The ventricles remain symmetric,
 and the cisterns are patent.  Generalized cerebral volume loss is unchanged.
 Periventricular white matter hypodensities are again noted.  The visualized
 paranasal sinuses and mastoid air cells are well aerated.  The calvarium is
 intact.


IMPRESSION:


No intracranial hemorrhage or mass effect.


TITLE:
   Chief Complaint:  Resp distress
   HPI:
   54F with multiple myeloma s/p autologous transplant undergoing active
   chemo with revilimidie, velcade, cytoxan, initially presented with
   asymptomatic (? N/V) fever to 100.4 and neutropenia on [**2115-1-17**]. She was
   pancultured and started on vanco and cefepime. During admission
   continued to spike fevers and was broadened to include voriconazole.
   Yest spiked to 103.4 associated with rigors, tachypnea (30s), desats,
   tachycardia to 120s. Viral cultures were sent, PCP treatment considered
   and LP done. RUQ US showed stones but no cystitis, cultures neg to
   date. Pt has no central access (PICC removed) but temp HD line was to
   be places for pharesis.
   .
   This morning, pt's respiratory status worsened, with desat to 80% on
   room air and tachypnea in 40s. ABG revealed Lactate 5.2, pH 7.4/28/121
   on nonrebreather.
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Vancomycin - [**2115-2-9**] 09:24 AM
   Infusions:
   Other ICU medications:
   Furosemide (Lasix) - [**2115-2-9**] 11:21 AM
   Other medications:
   OUTPATIENT MEDS:
   Acyclovir 400 mg po q8h,
   lenalidomide (revlimid) 15 mg po daily for two weeks each cycle,
   zoledronic acid monthly,
   ASA 81,
   Docusate prn
   .
   CURRENT MEDS:
   Tylenol prn,
   Fluconazole 200 mg po daily,
   Loperamide prn diarrhea,
   Ondansetron 8mg IV prn,
   Pantoprazole 40 mg po daily,
   Prochlorperazine prn
   Past medical


history:


Family


history:


Social


History:


- Multiple Myeloma: Destructive rib lesions found in [**2111**], treated with
   XRT for plasmacytoma. Later developed skull lesion, hypercalcemia and
   gradually increasing kappa plasma cells on BMBx. Pt underwent dendritic
   cell fusion gene protocol and 4 cycles of velcade/decadron.
   She underwent auto-SCT [**2113-10-16**] on "Vaccination with DC/Tumor cells
   fusion in conjunction with Autologous Stem Cell Transplantation
   in Patients with Multiple Myeloma" protocol. In [**3-29**] found to have a
   CNS plasmacytoma and underwent radiation therapy. Currently
   C1D20 on Velcade.
   - Irregular menstrual cycles (one per year), found to have an
   ovarian cyst.
   - Status post breast augmentation in ([**2079**]) by direct silicone
   injection
   - Gallstones
   She has no family history of cancer. Father died of CVA, mother died of
   speculated emphysema. She has one full brother and a half-sister.
   Occupation:


NICU Nursing Transfer Note


Baby girl [**Known lastname 4808**] is an X28week infant by exam. Mom had no
prenatal care until 26weeks when she states she found out
that she was pregnant. She delivered at approx 28weeks.
RESP: [**Known lastname 4809**] was intubated and rec'd one dose of
survanta. Self extubated to CPA within 12hrs of life then
quickley weaned to RA. RR 40-60's. CLear and equal with mild
IC/SC retractions (due to size, not WOB). She is on
caffeine.
CV: Soft int murmur audible. HR 130-160's. Pink, well
perfused. MAE.
FEN: Weight tonight 1095 (+35). BW 1055gm. TF 150 cc/kg/day
of BM22. PG fed over 40min. Abd is benign. No spits, min
aspirates. Voiding and stooling. Toleating feeds well.
DEV: Remains nested in sheepskin. MAE. Likes pacifier and
sucking on fingers for comfort.
HYPERBILIRUBINEMIA: AM [**Known lastname **] is pending.Currently under
single phtx.
SOCIAL: See SWS notes.
ID: S/P 48hr r/o for tx of potential sepsis.
A: Stbale, working up on calories.
P: Continue to eductae and support the [**Known lastname 26**].


Neonatology Attending
DOL 10 / PMA 32-3/7 weeks

In room air with no distress and no cardiorespiratory events (on  caffeine).

No murmur. BP 65/32 (44).

Wt 1615 (+35) on TFI 150 ml/kg/day SC26/BM26Prot, tolerating well by gavage. Abd benign. Voiding and stooling normally (guiac negative).

Temp stable in air isolette.

A&P
31 week GA infant with feeding immaturity, elevated 17OHP on state screen, possible GMH
-Continue to await maturation of oral feeding skills
-Advance caloric density to 28 kcal/oz
-Repeat state screen sent on [**3-16**]
-Repeat cranial ultrasound in 2 weeks
-No other changes in management as detailed above


ADdendum:

CVVHD dc'd per attending related to hypotension and now not tolerating
CVVHD.


