TITLE:
   Chief Complaint: C. difficile colitis and shock
   24 Hour Events:
   - Increased standing and sliding scale insulin for improved control
   - U/S at bedside of right chest found fluid, consider thoracentesis if
   would improve chance of extubation
   - Son, [**Name (NI) **] [**Name (NI) 2812**], [**Name (NI) 161**] re: tracheostomy. Son to visit [**2129-12-28**] noon
   for discussion, then will speak with her other brother in CA and tell
   team a decision in next 1-2 days
   - Diuresed -1L
   - Attempted to place NG x 2 -> both were in lung and removed
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Piperacillin - [**2129-12-25**] 06:05 PM
   Metronidazole - [**2129-12-28**] 03:55 AM
   Vancomycin - [**2129-12-28**] 06:00 AM
   Infusions:
   Furosemide (Lasix) - 3 mg/hour
   Other ICU medications:
   Pantoprazole (Protonix) - [**2129-12-27**] 08:00 PM
   Heparin Sodium (Prophylaxis) - [**2129-12-27**] 09:59 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  [**2129-12-28**] 07:31 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.7
C (99.8
   Tcurrent: 36.7
C (98.1
   HR: 92 (66 - 94) bpm
   BP: 115/50(66) {114/38(58) - 134/60(77)} mmHg
   RR: 18 (11 - 40) insp/min
   SpO2: 95%
   Heart rhythm: SR (Sinus Rhythm)
   Wgt (current): 75 kg (admission): 60 kg
    CVP: 0 (0 - 10)mmHg
   Total In:
                                                                  1,696 mL
                                                                    517 mL
   PO:
   TF:
                                                                    722 mL
                                                                    193 mL
   IVF:
                                                                    724 mL
                                                                    204 mL
   Blood products:
   Total out:
                                                                  2,555 mL
                                                                  1,145 mL
   Urine:
                                                                  2,555 mL
                                                                    645 mL
   NG:
   Stool:


Probable sinus tachycardia
Left axis deviation
Left bundle branch block
Since previous tracing, no significant change except for increased heart rate


CCU Nursing Progress Note 7p-7a
(Continued)
w. BS nml at present cont to follow w/ start of TF and cont Prednisone dosing. TLC removed early this am. ? Need for replacement. Cont to support pt and family as indicated.


pmicu npn 7p-7a


   the pt had an uneventful [** **]. he has been npo since mn in anticipation of a trach and peg.

review of systems

respiratory-> pt remains intubated and vented on psv8/peep5 and o2 35%. srr 20's w/tv ~700-800cc. most current abg on above settings: 7.41/35/121/23/-1. pt continues to require frequent suctioning for thick, white secretions. plan for trach in the or sometime later today.

cardiac-> pt is hemodynamically stable. he did receive a single dose of iv hydralazine for a sbp >160 earlier in the shift w/good results. sbp ranging 150-160's, but he was bolused several times for sbp >180 during his am bath as well. hr 90-100's, sr/st with no noted ectopy.

neuro-> pt is occationally opening his eyes when his name is called or when he is stimulated with suctioning/turning. he is not tracking. he is moving his arms laterally on the bed r>l. no change made to propofol qtt rate/all sedation off x48hrs.

gi-> abd is soft, distended w/+bs. he continues to pass liquid, brown, ob neg stool via the fib. tube feedings have been off since mn but residuals prior to mn were minimal.

gu-> uop ~10cc/hr. urine is now clear and yellow. anticipate dialysis later today. of note, pt to start on epogen during dialysis treatments today (hct has fallen to 24.7 today). +3 peripheral edema appears to have improved s/p ultafiltration yesterday.

id-> tmax 100.1 orally. wbc continues to trend downward to 11.9 this morning.

social-> no contact w/family [** 87**].


[**2140-7-9**] 12:35 PM
 CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST                     Clip # [**Clip Number (Radiology) 86431**]
 CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION
 Reason: fluid collection?, ascites?
 Admitting Diagnosis: FEVER
 Field of view: 36 Contrast: OPTIRAY Amt: 150
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


57F s/p donor R hepatic lobectomy, with known bile leak & now w fevers, s/p
  PTC


REASON FOR THIS EXAMINATION:


fluid collection?, ascites?
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


PROCEDURE:


CT of the abdomen and pelvis with contrast.


INDICATION:


Fevers.  Status post right hepatic lobectomy and percutaneous
 transhepatic catheter placement.


TECHNIQUE:


Multidetector, contrast-enhanced images of the abdomen and pelvis
 following the administration of 150 cc of IV Optiray were performed.  Images
 reformatted in the sagittal and coronal planes.

 IV CONTRAST:  Nonionic IV Optiray contrast was used as per protocol.

 CT OF THE ABDOMEN WITH CONTRAST:  There are new small, bilateral pleural
 effusions, right greater than left.  The patient is status post right lobe
 hepatectomy and embolization with coils of previous right transhepatic biliary
 catheter tract.

 Comparison is made to the CT study of [**2140-6-30**].  There has been interval
 placement 1 day earlier of a new, percutaneously placed, transhepatic biliary
 catheter through the segment II biliary ducts from midline approach. The tip
 ends in the right paracolic gutter adjacent to the right abdominal drain. Note
 is again made of the percutaneous biliary drainage catheter through the
 segment [**Date Range 67287**] biliary ducts with pigtail seen in the Roux loop.

 New on the current exam is a large, retrohepatic,  mixed high-density,
 expansile collection measuring 9.6 x 5.7 cm.  It demonstrates mass effect on
 the adjacent inferior vena cava and liver.  There is nonenhancing irregularity
 of the liver parenchyma anterior to this collection. There is new attenuation
 of the proximal, intrahepatic main left portal vein branch, which is
 surrounded by periportal fluid.  The newly inserted biliary drain through the
 segment II ducts is noted to traverse branches of the intrahepatic arteries.

 There is a small amount of diffuse free fluid throughout the abdomen. Focal
 high density seen within the fluid in the left paracolic gutter suggests the
 the etiology to be hemorrhage.  The spleen is markedly enlarged. Kidneys,
 adrenal glands, pancreas, stomach, and bowel loops are unremarkable in
 appearance.  The aorta is normal in caliber, without evidence of dissection.
 The main visceral arterial branches are patent.

                                                             (Over)

 [**2140-7-9**] 12:35 PM
 CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST                     Clip # [**Clip Number (Radiology) 86431**]
 CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION
 Reason: fluid collection?, ascites?
 Admitting Diagnosis: FEVER
 Field of view: 36 Contrast: OPTIRAY Amt: 150
 ______________________________________________________________________________


FINAL REPORT


(Cont)
 CT OF THE PELVIS WITH CONTRAST:  The bladder and distal ureters are normal.
 There is a small to moderate amount of free fluid in the pelvis.  Pelvic bowel
 loops are normal.  Foley catheter is seen within the bladder.

 Bone windows show no suspicious lesions.

 MULTIPLANAR REFORMATTED IMAGES:  Images reformatted in the sagittal and
 coronal planes demonstrate percutaneous transhepatic biliary drainage
 catheters and large retrohepatic mixed and high attenuation, expansile
 collection consistent with acute hematoma.


IMPRESSION:


1.  New expansile, retrohepatic, mixed high-attenuation collection with mass
 effect on the IVC and adjacent liver, consistent with a hematoma. Small to
 moderate serosanguinous fluid is seen throughout the abdomen and pelvis.
 2.  Nonenhancing hypodense irregularity of the liver margin anterior to the
 aforementioned collection, the appearance for which tear/laceration of the
 liver capsule and/or parenchymal liver injury is possible.
 3.  Irregularity and attenuation of the proximal intrahepatic left main portal
 vein.

 A small focus of high attenuation seen on series 2, image 18 at the periphery
 of the retrohepatic collection could indicate an element of active
 extravasation from arterial injury.  The above findings were called
 immediately to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28801**] of the surgical team caring for the patient.


Nusing Progress Note
I have examined this infant.  I agree with PCA [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 968**]' note and assessment.


[**2150-3-22**] 8:26 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 4469**]
 Reason: please evaluate for ett placement
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


66 year old woman with SAH


REASON FOR THIS EXAMINATION:


please evaluate for ett placement
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


66-year-old woman with subarachnoid hemorrhage.  Please evaluate
 for ET placement.


COMPARISON:


None available.

 ONE VIEW OF THE CHEST:

 The lungs are low in volume and show a right lower lobe opacity. An ET tube
 terminates 1 cm above the carina.  Distal aspect of a nasogastric tube
 terminates overlying the lower left hemithorax.  While it does not appear to
 course in the path of the left mainstem bronchus, the nasogastric tube may be
 in a hiatal hernia, although pulmonary involvement can not be excluded.
 Another tube overlies the neck and is likely external. An EJ catheter is noted
 in the right neck. No effusions are noted. Prominence of the mediastinum may
 be secondary to patient position and AP technique.  A rib deformity in the
 right lower lobe likely represents an old fracture.


IMPRESSION:


Mild right lower lobe opacity likely represents atelectasis. While it does not
 appear to course in the path of the left mainstem bronchus, the nasogastric
 tube may be in a hiatal hernia, although pulmonary involvement can not be
 excluded  Nasogastric tube was removed [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3057**], the ED resident,
 when this finding was communicated.

 Endotracheal tube slightly low lying, terminating ~ 1 cm above the carina and
 should be withdrawn approximately 2 cm.

 Prominence of the mediastinum may be due to patient position and AP technique.
 If clinical concern for acute aortic syndrome suggest PA and lateral views, or
 if patient not able consider chest CTA.


[**2101-5-13**] 3:42 PM
 CHEST (SINGLE VIEW)                                             Clip # [**Clip Number (Radiology) 25384**]
 Reason: ASSESS EFFUSIONS/INFILTRATES
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


74 YO WOMAN S/P CABG AND CT REMOVAL


REASON FOR THIS EXAMINATION:


ASSESS EFFUSIONS/INFILTRATES
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


74-year-old S/P CABG and chest tube removal assess
 effusion/infiltrates.


COMPARISON:


[**2101-5-10**]

 PORTABLE CHEST:  Sternotomy wires and surgical clips are present consistent
 with prior CABG.  There are mid-line skin staples seen.  The cardiac
 silhouette is enlarged and there is bilateral pleural effusions with bilateral
 interstitial edema which have worsened compared to the prior study.  The
 visualized bones are unremarkable.


IMPRESSION:


Cardiomegaly with bilateral interstitial edema and effusions
 consistent with failure.


NPN 0700-[**2086**]


1.  On 120/k/d min. of BM20/E20.  Infant taking 50-90cc
Q3-4hr very well.  Voiding and stooling.  Abd benign.
Tolerating all PO feeds well.

2.  Temp stable swaddled in OC.  Infant waking for feeds
Q3-4hr and resting well inbetween.  MAE, brings hands to
face.  AGA.  Newborn screen sent.

5.  No A&B's.  Lungs clear, RR 30-50's with sats 98-100%.
Stable resp status.  Day [**5-21**] brady countdown.

3.  Parents in to visit.  All d/c teaching reviewed as noted
on NICU D/C instruction sheet.  Reviewed administation of FE
and polyvisol.  Parents placed infant in carseat.  Baby d/c
home with belongings and parents.


51 y/o man w/ PMH of C3-C5 spinal cord contusion, L femur fracture, rib
   fx
s, and liver laceration for car accident. Was in T/SICU from [**11-3**] to
   [**11-17**]. Pt was not a surgical candidate for spinal repair, surgical
   repair performed on L femur.  IVC filter was placed r/t possible PE and
   pt received trach/PEG. Discarged to [**Hospital3 1536**] but was re-admitted
   to [**Hospital1 5**] r/t increased oxygen requirement and fevers up to 104 degrees.
   Admitted to M/SICU for further mgt.  Pt is Full [**Name (NI) 156**]..
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 76**])
   Assessment:
   Remains intubated.
   Received pt on PSV 18/5, FIO2 40%.
   02 sats 98-100%
   Sm/moderate amt white thick secretions via ETT.
   LS rhonchi bilaterally.
   HR/BP stable, urine output adequate, tolerating TF
s at goal rate.
   Pt sleeping soundly throuhout night, easily arousable.
   Action:
   PSV reduced from 18 -> 16.
   Changed to MMV r/t low RR and MV when pt sleeping.
   Response:
   Pts resp status stable on PSV/MMV settings. (see flowsheet).
   Plan:
   Cont to monitor pts resp status.
   Wean vent support as tolerated.
   Fever, unknown origin (FUO, Hyperthermia, Pyrexia)
   Assessment:
   Pt febrile to 101-102 at start of shift, on cooling blanket.
   Action:
   Received 800mg Motrin at start of shift for headache/fever.
   Response:
   Temp trending down overnight 101.1 -> 99.9.
   Cooling blanket D/C
   Plan:
   Cont to monitor pts temp.
   Impaired Physical Mobility
   Assessment:
   Pt able to move toes on both feet slightly on command.
   No movement in hands noted.
   Pt remains in [**Location (un) 408**] J collar.
   Action:
   Collar care performed.
   Pt turned side to side off back in bed.
   Response:
   Remains physically immobile.
   Skin dry and intact, no breakdown noted.
   Plan:
   Cont to monitor pts physical mobility.
   Cont to turn off back and provide collar care to prevent skin
   breakdown.


CCU ADMITTING NOTE
58 YEAR OLD MALE ADMITTED TO CCU POST CATHETERIZATION & SHEATH PLACEMENT.

ALLERGIES: NKDA

PMH: Interior wall MI, CAD-(MULTIPLE SIBLINGS DIED OF PREMATURE CAD),       HTN, +CHOL, HYPERLIPIDEMIA, TOB USE 2-3PPDX30YRS> QUIT 10 YRS          AGO.
     CABG '[**01**] WITH LIMA TO LAD, SVG TP D2, SVG TO OM.
     CATH [**4-/2109**] WITH STENT PLACEMENT TO NATIVE MID RCA
     [**11-6**] 3VD PATENT SVG TO OM2- OCCLUSIVE SVG TO DIAG, PATENT LIMA TO LAD, PATENT STENT TO THE MID RCA, PROX RCA HAD A FOCAL 80% STENOSIS & DISTAL RCA HAD A SEVERE FOCAL 90% STENOSIS PRIOR TO ORIGIN OF THE rPDA s/p stent placement to prox & distal RCA.

ADMITTING HX: PT RECENTLY C/O ^SOB WITH EXERTION. WENT FOR ROUTINE ETT C/O CP. ST DEPRESSIONS SEEN IN V5, V6,I & aFL with max st depressions in V5. Nuclear medicine revealed severe reversible defect in distal anterior & apical walls. Severe partial reversible defect in the inferior LV wall. LV dilation @ stress, suggestive of ischemia. Global HK with sn EF of 40% noted. Pt went to cath on [**7-16**] found to of proximal LAD & proximal LCX. 60% midsegment stenosis in prev stented RCA. SVG-D1 known occl. SVG to OM1 midsegment w/ 80% focal lesion LIMA_LAD was patent w/LAD after touchdown TO. The SVG & OM1 was stented but infer pole outflow vessel of the OM had mod slow flow after intervention & was recrossed & dilated restoring flow. Superior pole was dilated and restored as well.  Pt entered V-fib arrest on floor secondary to thrombosis fo OM inferior pole vessel., defib X1, IVB amiod. EKG exhibited st^ in anterolateral leads which lead to recatheterization. 2nd PCI revealed stent patency but occlusion of inferior pole. CP resolved after inferior pole was reopened. Given 320cc of contrast. Arrived w/ no C/O CP but nausea. No vomiting occurred.

NEURO: A&OX3. COOPERATIVE & APPROPRIATE. C/O BACK PAIN D/T CATH PROCEDURE. GIVEN MORPHINE 1MG X2 WITH MINIMAL EFFECT. GIVEN 2MG MORE WITH MOD EFFECT. GIVEN 5TH MG & SERAX @ 0100. PT SLEPT SOUNDLY UNTIL 0500.

CV: NO C/O CP. HR 69-77 W/ PVC'S RARE-OCCASSIONAL. NBP 87-118/40-59. ABP 124-140/55-66. SHEATH PULLED @ 2300. PRESSURE APPLIED FOR 20 MIN. - OOZE OR HEMATOMA PRESENT. TRANS DSG APPLIED C&D. DP +2, PT +1. PT ON [**Name (NI) 5952**] 2 MCG/KG/MIN. RECEIVING 2 LITER OF 2 OF IVF. INITIAL LITER D5 1/2NS GLUCOSE 238, 2ND BAG CHANGED TO 1/2 NS 125CC/HR. AM GLUC 144
HCT 35.2. K+ 3.6, CA 8.5, phos 5.0, MG 1.7, CK 825. CK/MB 128

RESP: NO C/O SOB. LUNG SOUNDS CLEAR. RR 12-19. O2 SATS 95+ ON 3.0 L VIA NC.

ID: AFEBRILE. MAX PO TEMP 97.4. WBC 14.4.

GI/GU: NPO EXCEPT WITH MEDS. C/O NAUSEA UPON ADMISSION. +BS ALL 4 QUADRANTS, -BM. CONDOM CATH DRAINING CLEAR YELLOW URINE. USING URINAL  @ 0600 W/OUT DIFFICULTY. RECEIVED 320 CC OF CONTRAST DURING STUDY- BUN/CR 11/0.7.

SKIN: WNL

ACCESS: LEFT WRIST #20G.

DISP: FULL CODE
SOCIAL: FAMILY VISITED.

A: POST CATH TOLERATED WELL. SHEATH PULLED TOLERATED WELL. - COMPLICATIONS.

P: FOLLOW CURRENT MEDICAL MANAGEMENT & C/O PT TO FLOOR. SUPPORT PT WHERE INDICATED. SOCIAL WORKER [**Name (NI) 5953**] PT [**Name (NI) **]


[**2173-10-22**] 7:44 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 72198**]
 Reason: placement of right subclavian line (replaced this am)
 Admitting Diagnosis: CONGESTIVE HEART FAILURE
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


58 year old obese man s/p cardiac cath, with long history of CHF,  p/w
          cardiac stent  thrombosis.  s/p line placement.


REASON FOR THIS EXAMINATION:


placement of right subclavian line (replaced this am)
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


New right subclavian line. Respiratory distress.

 COMPARISONS: [**2173-10-21**]

 SINGLE VIEW CHEST, AP SEMI ERECT:  These films are again technically limited
 views due to patient's body habitus.  It appears the right subclavian central
 venous line tip is within the distal right subclavian vein.  The tracheostomy
 tube appears in proper position within the trachea.  The right IJ central
 venous line tip within the SVC appears unchanged.  The nasogastric tube is
 seen coursing below the diaphragm.  Proper evaluation of the lung fields is
 not possible.


IMPRESSION:


Right subclavian central venous line tip within distal right
 subclavian vein.


Sinus rhythm, rate 75. Since the previous tracing of [**2148-4-25**] the
electrocardiogram is essentially unchanged.


Respiratory care:
Patient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient ps increased last night as Respiraotry rate went up into the 40's. She was more comfortable after ps increased to 10cm.  RSBI this am 80. Breathsounds are coarse. Please see respiratory section of carevue for further data.
Plan: Continue mechanical ventilation. Continue to wean as tolerated.


[**2195-3-15**] 10:21 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 41178**]
 Reason: eval for PNA
 Admitting Diagnosis: BILE DUCT OBSTRUCTION
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


79 year old man with fever


REASON FOR THIS EXAMINATION:


eval for PNA
 ______________________________________________________________________________


FINAL REPORT


AP CHEST, 10:29 P.M. ON [**3-15**]


HISTORY:


Fever, rule out pneumonia.


IMPRESSION:


AP chest compared to [**2-2**]:

 New consolidation and moderate left pleural effusion are readily explained by
 pneumonia and possible empyema.  Conceivably simple pleural effusion could
 explain most of the abnormalities, by virtue of relaxation atelectasis.

 Heart size is normal.  Right lung is clear.  Right pleural effusion, minimal
 if any.  No pneumothorax.


Respiratory Care
Pt cont on CPAP. fio2 .25-.28, bs clear, rr 50's with mild retractions. sx for mod amt. On caffeine. No spells. Plan to trial off CPAP in am.


Neonatology NP Note
PE
swaddled in open crib, cobedding with twin
AFOF,sutures opposed
comfortable respirations in room air, lungs clear/=
RRR, no murmur, [** 211**] and well perfused
abdomen soft, nontender and nondistended, active bowel sounds
active with good tone


[**2139-2-13**] 6:13 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 8775**]
 Reason: Eval acute process
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


63 year old woman with CP


REASON FOR THIS EXAMINATION:


Eval acute process
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Chest pain.

 No comparison studies available.

 FRONTAL CHEST RADIOGRAPH:  There is moderate cardiomegaly.  A moderate-sized
 right pleural effusion is present.  Central pulmonary vessel congestion and
 mild interstitial edema is seen.  There is no pneumothorax.


IMPRESSION:


CHF.


PATIENT/TEST INFORMATION:


Indication:


Coronary artery disease. Left ventricular function.  Preoperative assessment.
Height: (in) 65
Weight (lb): 152
BSA (m2): 1.76 m2
BP (mm Hg): 156/77
HR (bpm): 60
Status: Inpatient
Date/Time: [**2119-5-25**] at 15:00
Test: Portable 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 and cavity size. Low normal LVEF. No
resting LVOT gradient. No VSD.

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

AORTA: Mildy dilated aortic root. Normal ascending aorta diameter. Normal
aortic arch diameter.

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

MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA
systolic pressure.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.
Physiologic PR.

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium and right atrium are normal in cavity size. Left ventricular
wall thicknesses and cavity size are normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal. The aortic
root is mildly dilated at the sinus level. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no aortic stenosis
or aortic regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.


IMPRESSION:


Low-normal left ventricular systolic function. No significant
valvular abnormality seen.


Respiratory Care

  Pt continues on full ventilatory support. PEEP decreased as documented. B/S sl coarse sx'd scant. Will continue to follow closely.


NPN 1900-0700

Pt status unchanged. Stable throughout night except for resp issues. Requires frequent suctioning for mod to copious amt of secretions. Several times pt brady in 50s and sats dropped to 88% due to copious secretions. VS stabilized after sxing. Anbx changed per ID, zosyn d/c'd and levoquin and flagyl added. Afebrile. Erythema on thighs and abd remains dark red and warm to touch.


Pt adm from home after found by his HCW, SOB, pale and diaphoretic. In
   the EW, Hct found to be 26 down from high 30's. Gastric lavage showed
   coffee ground. Pt HD stable. CE (-). Pt sent to MICU for further care.
   EVEVTS:
   [**1-31**]: EGD
   Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)
   Assessment:
   Pt with presumed UGIB s/p melanotic stool on [**1-29**] in AM requiring
   blood transfusions to maintain HCT value > 25.  So far received 7 units
   of PRBC transfusion.  Pt received one unit of PRBC
s this AM for HCT
   value of 24.4 with a bump to 27.2 two hours after completion of
   transfusion.  .  Pt received/maintained on IV Pantoprazole gtt infusing
   @ 8mg/hr. No  melanotic stool this AM.  Pt remains NPO for EGD.  Abd is
   soft with positive BS.   The patient is hemodynamically stable.
   Abdomen soft , distended, patient passing gas but no stoolong yet.
   Action:
   Pt Received 7 th unit of PRBC for this shift via PIV.  EGD done today
   at 0900 am. Received 0.5 mg Midaz X3 (Total : 1.5 mg) & Fentanyl 25 mcg
   for the procedure. Cauterized the bleeding point successfully.
   Catheterize the patient , urine sample sent for culture. 1100 cc urine
   noted soon after  the catheterization.
   Response:
   Last HCT value : 27.2. Patient tolerated EGD well. No melanotic stool
   this shift. Last Hct at 1500 hrs : 26.9. Please see the graph below.
   Plan:
   Cont PPI . Cont monitoring for other s/s of bleeding. Goal Hct >25.
   transfuse PRBC if Hct<25. Check Hct Q 6 hourly. Last Hct due at 2100
   hrs. If Hct remains stable possible call out [**Doctor First Name 600**].
   Hypernatremia
   Assessment:
    AM Na : 145. Patient is NPO.
   Action:
    Started  on  D5W @ 125 ml/hr for 1000 ml X2 . Rechecked Lytes at 1500
   hrs.
   Response:
    At 1500 Hrs : Na; 147.  Order to continue for additional 1 L of D5W.
   Plan:
   Recheck Lytes at 2200 hrs.
   Delirium / confusion
   Assessment:
   The pt on Scheduled Quetiapine [**Hospital1 **]  for agitation/confusion today.  The
   pt has been AAO times one/ zero today.  Pt unable to answer most simple
   yes/no questions.  Pt is unable to articulate . Patient is very
   agitated towards the afternoon. Given 12.5 mg of additional seroquel
   PO. But  seems not responding .
   Action:
   Soft wrist restraints along with 1:1 sitter @ BS for pt safety.  Pt
   freq re-oriented to person/place/time to [**Doctor Last Name 3777**] comfort.   Lights
   softened to promote pt comfort.  Family members encouraged to
   visit/interact with pt to [**Doctor Last Name 3777**] pt comfort.  Seroquel 12.5 mg PO X1
   given as PRN dosage. Switched to Halodol IV 0.5 mg X1   . QTc : 440 ms.
   Response:
   The pt rested after receiving Fentanyl 25 mcg & midaz 1.5 mg for the
   EGD procedure.   Seroquel with minimal response for agitation. Halodol
   0.5 mg Iv X1 with good effect.
   Plan:
   Cont to promote pt comfort, medicate active agitation/delirium,
   encourage supportive family members to visit/ interact with pt,
   validate pt feelings, maintain sitter/soft wrist restraints for
   safety.  EKG fpr QTC interval.


Resp Care
[**Age over 90 404**] y/o M admitted from ER with Hx of HTN, CHF, s/p fem [**Doctor Last Name **] bypass and was intubated due to increased resp distress. Pt remains on A/C with no changes made t/o shift (please see careview for specifics). BS essentially clear sxing for small to mod amts of thick white secretions. Pt oxygenating well on 40%. Will cont to monitor and assess for readiness to wean.


50 yo Caucasian male transferred to [**Hospital1 19**] with a large hypertensive
   IVH. Patient w/h/o HTN was at a wedding two weeks ago when he suddenly
   became confused and combative c/o severe HA. He presented to [**Hospital1 2020**] via EMS and continued to be combative and confused and
   complaining of severe headache located in the back of his head.  He was
   intubated and a head CT there showed a large IVH with blood in the 3rd
   and 4th ventricles with hydrocephalus and cerebral edema.  SBPs in the
   250s that were non-responsive to labetalol, but responded to propofol.
   Per report, he has a history of  hypercholesterolemia and had stopped
   his medications for the last year [**1-15**] financial difficulties. Dilantin
   load given at [**Hospital3 735**]. He arrived to the [**Hospital1 19**] ED with SBP in
   180s, sedated on propofol. He was brought emergently to the OR for
   placement of bil IVD.
   v     [**12-3**]    Transferred to step-down unit
   v     [**12-6**]     Transferred to t/sicu with LLE DVT and Bilateral PE
   v     [**12-6**]    Transferred to MICU 7 with LLE DVT & Bilat PE
   v     [**12-7**]    Extubated electively.
   Pulmonary Embolism (PE), Acute
   Assessment:
   Received patient on Heparin gtt at 2000units/hr . Lt Fem angio site
   C/D/I s/p  IVC filter placement . DVT @ left leg. Ace wrap @ left leg.
   Pedal pulses  doplerable bilat. Left  toes  purple .
   Action:
   Last three PTT  has been therapeutic . Contd Heparin gtt @ [**2160**]
   units/hr  as per protocol.
   Response:
   PTT  @ this shift : 82.9/76.9/74.8.  heparin gtt   contd @
   2000units/hr.
   Plan:
   PTT QD. Goal PTT 60-100
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   S/P extubation yesterday. Received patient on 4 L NC.  Lungs clear at
   upper lobes bilat & diminished at bases.
   Action:
   Weaned O2 to 2 L NC.
   Response:
   Satting at high 90
s & RR 20-30
   Plan:
   Continue to monitor resp status .
   Intracerebral hemorrhage (ICH)
   Assessment:
    Both Pupils 5 mm & brisk.  Mental status waxing and [**Doctor Last Name 533**] but pt is
   arousable and has periods of alertness and periods of confusion and
   periods of somnolence.  Oriented to self only.  Sister states this has
   been his norm since the initial incident.
   Action:
   Neuro status checks q 4 hours.    ICP drains monitored closely and
   releveled as needed.  Receiving PO keppra.   Pt able to take PO pills.
   Response:
   ICP drainage# 1 & # 2 draining bloo tinged. Drainge amount has been
   reduced  than yesterday.  Till midnight total ICP drainage : 124 ml.
   ICP ranging from4-8.    Head dsg  changed.
   Plan:
   Continue to monitor neuro checks frequently and alert team to any acute
   changes.    Continue to monitor and maintain ICP drains closely and
   notify team for signif changes.
   Hypertension.
   Assessment:
   Pt has remained off pressors>24 hours..   BP ranging 140-180 systolic
   Action:
   Hydralazine 10 mg IV given x1, fentanyl 12.5 mg IV given. Metaprolol 5
   mg IV given X1 for Goal SBP 110-160
   Response:
   BP remains  at  140-150
s after  metaprolol & hydralazine
   administration.
   Plan:
   Cont monitoring SBP closely. Goal SBP 110-160
s. will restart Clonidine
   patch today  . Hydralazine PRN IV if needed.


MICU NPN Update:
Pt has been called out to the floor for further care. Will d/c cordis and send to the floor this evening.


[**Last Name (LF) 4513**],[**First Name3 (LF) 4514**]                  NMED FA11                  [**2163-4-12**]  8:07 AM
 MR HEAD W & W/O CONTRAST                                        Clip # [**Clip Number (Radiology) 96139**]
 Reason: fMRI needed to map the speech center as requested by Dr [**Last Name (STitle) **]. T
 Admitting Diagnosis: INTRACRANIAL HEMORRHAGE
  Contrast: MAGNEVIST Amt: 12
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


57 year old woman with a L parietal AVM which has hemorrhaged


REASON FOR THIS EXAMINATION:


fMRI needed to map the speech center as requested by Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] & Dr [**Last Name (STitle) **].
  [**Doctor Last Name 294**]
 No contraindications for IV contrast
 ______________________________________________________________________________
                                  PFI REPORT
 1.  Stable left parietal intraparenchymal hemorrhage, similar in size and
 distribution.

 2.  Multiple nonspecific FLAIR hyperintensities in a callosal-septal striation
 pattern.  This raises the question of multiple sclerosis; however, the
 differential remains _____ and includes other conditions such as vasculitis.


PATIENT WITH QUIET NIGHT ABG'S IMPROVED WITH SEDATION GOOD ABG ON 60% WITH 16PEEP, ETSECRETIONS THICK MODERATE TO SCANT. SAO2 94%-99%. SR IN THE 80'S SBP 100-120'S WITH ICREASED VS  SBP TO 160'S WITH SUNCTIONING OR TURNING.. AFEBRILE.. RESP AS NOTED BILATERAL BS COARSE, MINIMAL TO MODERATE THICK SECRETIONS, ABG PENDING AT 4AM.. GU GOOD U/O WITH LASIX INTIALLY 5MG THEN 3MG/HR. KREPLACED AS ORDERED, WITH K PENDING THIS AM. GI NGT TO LCS DRAINING PINK SCERTIONS.. ABD. SOFT SLIGHTLY DISTENED, HTPOACTIVE BS.. ABD INCISION CLEAN  NEW DSD PLACED. PEDAL PULSES PALABLE, CSL ON.. CONTINUES ON VANCOMYCIN/CIPRO.ON PLAVIX FORSTENT. ALSO ON HEPARIN SC/ASA. PLAN CONTINUES TO DUIRESIS, ?? HOW TO WAKE UP AND WEAN WITHOUT MAJOR RESP COMPROMISE ??PRECEDEX..


Respiratory Care Note
Pt remains on nasal cannula @1l FIO2 47-53%.  B.S. clear with good air entry.  As of this time 2 bradys noted, caffeine dc'ed.


CCU NPN 7A-3P
Neuro: Sedated with fentanyl @ 60mcg and versed @ 2mg.  Not following commands, grimaces to pain and suctioning, non-purposeful movements of upper extremities.

CV: ABP down to 79/39 with MAP 50 via R radial Aline, CVP 9.  Started on levo @ 2.7mcg/min, given 600ccNS bolus.  After bolus and 1uPRBC CVP up to 15.  Levo titrated down to 2.1mcg/min, ABP 111/55 with MAP 74.
Hep@1300u/hr, PTT 61.7, no change.  Turned off at 1200 for Quintin placement, restarted after placed @ 1300u without bolus.

Pulm:  LS-crackles at bases, coarse in upper lung fields.  Intubated,  cont on PEEP 5 PS 25 FiO2 40% TV 400-500.  Last ABG 7.47/41/91/31.  Waiting for trach placement.

GI/GU: Ultracal @65cc/hr, residual 2hrs. after kaexylate 180cc, TF held.  Will recheck and restart TF as [** **].  Total 225cc u/o today, +2700cc today, 18.5L LOS.  Creat 2.5, Quintin [** **] placed.  To start CVVHD this afternoon.

Labs: Hct 28.5, 2uPRBC ordered, 2nd unit currently infusing.  K 6.0, given 60mg kaexylate, down to 5.1.

Skin: Duoderm on coccyx fell off, necrotic decubitus ulcer with sanguinous drainage present.  Skin around ulcer red and friable.  Waiting for plastics consult, DSD covering ulcer to protect skin in meantime.  Skin barrier applied, turned Q2hrs, placed on kinair bed.

ID: WBC 17.0, Tmax 100.2R.  Continues on cefepime 2gm Q24hr.

Social: Husband updated by RN, daughter updated by HO.  Still want full treatment, full code.

Plan: Start CVVHD, recheck Hct and K tonight.  Waiting for plastics consult for wound care.


Shift Note 7am-7pm
(Continued)
off.


Respiratory Care Note
Infant received on settings of 22/5, R28 - weaned to R 24 today per ABG's - most recent 7.29/35/55/18/-8 (R26) - FIO2's mostly 26-38% with some drifts. BS coarse, sx mod cloudy secretions - audible air leak - remains on antibiotics, Dopamine discontinued - continue to monitor, wean [** **] settings as tolerated.


NSG NOTE
ROS:

     CV:NIPRIDE TO MAINTAIN SYS BP<140.AFTER PROPOFOL INCREASED TO BETTER SEDATE PT FOR CT/XRAYS,NIPRIDE ABLE TO BE WEANED OFF.WILL USE NICARPIDINE QTT IF BP CONTROL NEEDED.T MAX 100.3.REMAINS IN NSR WITHOUT ECTOPI.

      RESP:PT ON CPAP WHEN SHIFT STARTED.AGITATED WITH RR 30'S SO PT HEAVILY SEDATED WITH PROPOFOL AND PUT ON CMV UNTIL HEAD CT AND TLS FILMS DONE AND READ.ONCE TLS CLEARED,WILL WEAN AND EXTUBATE PT.

       NEURO:APEARED AWARE BEFORE SEDATION INCREASED.NODDED APPROPIATELY AND FOLLOW COMMANDS.PUPILS =&+.

       GU:ADEQUATE UO.

       GI:NPO,ON IVF,OGT DRNG LARGE AMT GREEN FLD.

       SOCIAL:[**Doctor First Name 901**](SIGN OTHER)AND SISTER IN.SHE IS AWARE OF PLANS,RXS,ETC.ALSO SPOKE TO SOCIAL WORKER.


Neonatology Attending Progress Note

Now day of life 10.

Current vent support - HFOV MAP 10 amp 16 and in 21-46% FIO2
CBG prior to wean on amplitutde 7.44 39 42
No apnea and bradycardia noted.
On caffeine.
HR 140-160s
MAP in the 30s.

Wt. up 15gm to 590gm on 130cc/kg/d of PN/IL
NPO because of abnormal gas pattern noted previously.
Latest KUB gas pattern changed - [**Doctor Last Name **]

ID - blood culture positive for G-neg rods, now on amp, gent and cefotaxime

Lytes 139 5.3 101 21

Bili 3.2 off phototherapy

Hct 37 post transfusion

HUS - no abnormality noted

Assessment/Plan:
Much more stable day today.
Will continue on HFOV.
Continuing to follow abdomen closely for any evidence of NEC.
Will adjust antibiotics when organism and sensitiviites are available.

[**Doctor Last Name 2**] up to date on status.


[**2135-3-29**] 7:27 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 51676**]
 Reason: fever cough
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


65 year old woman with cough,pleuritic cp, hx copd now  with broncho-vesicular
  bs in rll


REASON FOR THIS EXAMINATION:


fever cough
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Fever and cough.

 Portable upright frontal radiograph.  Comparison [**2135-3-1**].


FINDINGS:


The cardiac and mediastinal contours are within normal limits.
 There is patchy opacification in the right lower lobe.  The left lung is
 clear.  There are no pleural effusions and the pulmonary vasculature is
 normal.


IMPRESSION:


Right lower lobe pneumonia. Follow up after treatment may be
 obtained to ensure resolution.


Admission Date:  [**2124-7-27**]              Discharge Date:   [**2124-8-8**]

Date of Birth:  [**2056-1-1**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Indocin

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain/Fatigue/DOE

Major Surgical or Invasive


Procedure:


[**2124-7-27**] - Redosternotomy, CABGx3(Saphenous vein graft
(SVG)->Diagonal artery, SVG->Ramus artery, SVG->Posterior left
ventricular artery), MVR(33mm St. [**Male First Name (un) 923**] 33mm Porcine Valve)
[**7-29**] - Reexploration for bleeding
[**8-1**] - Permenant pacemaker placement.


History of Present Illness:
The patient is a 68-year-old gentleman who underwent coronary
artery bypass grafting for critical symptomatic congestive heart
failure symptoms back
in [**2124-1-15**] up in [**Location (un) 5450**], [**Location (un) 3844**].  The patient
re-presented with a bout of congestive heart failure and Dr.
[**Last Name (STitle) 78250**] worked the patient up, which showed that all of his vein
grafts were occluded.  His mammary artery was
patent to the LAD and there was severe native vessel progression
as well.  This degree of mitral regurgitation had significantly
increased as well between [**Month (only) 1096**] and this point.  The patient
was therefore referred for redo coronary
artery bypass grafting as well as mitral valve repair or
replacement.

Past Medical


History:


CAD s/p CABGx6 in [**1-/2124**]
CVD
COPD
Hyperlipidemia
HTN
AAA
PNA
MI
DJD
Gout
CRI
h/o alcohol abuse
Renal cell cancer s/p nephrectomy
CHF
CVD s/p (B) CEA

Social


History:


Lives with wife in [**Name (NI) **]. Quit smoking two weeks ago. Former heavy
drinker, currently drinks three beers daily.

Family


History:


Unremarkable

Physical


Exam:


74  112/62  67"  188lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM. (B) CEA incisions.
LUNGS: CTA bilaterally
HEART: RRR, No R/G, I/VI systolic late blowing murmur, well
healed sternotomy
ABD: Soft, ND/NT/NABS. well healed right nephrectomy incision.
EXT:warm, well perfused, no bruits, no varicosities, L GSV
harvested Right appears suitable. Mild peripheral edema
NEURO: No focal deficits. Uses cane for walking d/t left hip
arthritis.

Pertinent Results:
[**2124-7-27**] - ECHO
Pre Bypass: The left atrium is markedly dilated and elongated.
Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is an inferobasal left ventricular
aneurysm. There is severe regional left ventricular systolic
dysfunction with an inferior basal aneurysm with akinesis of the
basal inferior and inferior-septal walls. There is also severe
hypokineis of the entire lateral and remaing portions of the
inferior and septal walls, and mild hypokinesis of the anterior
and anteroseptal walls. LVEF 20%, but given severity of MR, this
is likely an overestimation of actual LV function. Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the aortic arch. There are three
aortic valve leaflets. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The mitral regurgitation vena contracta is >=0.7cm (0.8 cm).
There is no pericardial effusion.

Post Bypass: No change in Biventricular function. There is a
bioprosthetic mitral valve in place, no paravalvular leaks.
Aortic contours intact. Remaing exam is unchanged. All finidngs
discussed with surgeons at the time of the exam.


PROCEDURE:


Chest PA and lateral on [**2124-8-7**].


COMPARISON:


[**2124-8-3**].


HISTORY:


68-year-old man with status post MVR and CABG, rule out
effusion.


FINDINGS:


The loculated right hemithorax effusion including the
fissures have
remained stable. The small present left pleural effusion has
decreased in
size on today's examination. Persistent cardiomegaly is
moderate. The left
subclavian dual-lead pacemaker is unchanged in location. Left
retrocardiac
atelectasis is more pronounced on today's examination. The
pulmonary
vasculature is slightly prominent but no definite edema is seen.


IMPRESSION:


1. Loculated right small to moderate pleural effusion, stable.
2. Improvement of the small left pleural effusion.
3. Moderate cardiomegaly.

[**2124-8-7**] 01:43AM BLOOD WBC-12.2* RBC-3.00* Hgb-8.6* Hct-26.8*
MCV-90 MCH-28.6 MCHC-31.9 RDW-15.2 Plt Ct-611*#
[**2124-8-6**] 04:35AM BLOOD Hct-27.7*
[**2124-8-2**] 02:20AM BLOOD PT-12.9 PTT-22.6 INR(PT)-1.1
[**2124-8-7**] 01:43AM BLOOD Glucose-94 UreaN-23* Creat-1.0 Na-133
K-4.6 Cl-97 HCO3-29 AnGap-12

Brief Hospital Course:
Mr. [**Known lastname 6164**] was admitted to the [**Hospital1 18**] on [**2124-7-27**] for surgical
management of his coronary artery and vein graft disease. He was
taken directly to the operating room where he underwent a
redosternotomy with coronary artery bypass grafting to three
vessels and a mitral valve replacement using a 33mm St. [**Male First Name (un) 923**]
porcine valve. Please see operative note for details.
Postoperatively Mr. [**Known lastname 6164**] was transferred to the intensive care
unit for monitoring. He initially required inotropes and packed
red blood cells for pressure support and anemia. Complete heart
block was noted under his temporary pacemaker and the EP service
was consulted. A pacemaker was likely needed. He was
successfully extubated on postoperative day one. On
postoperative day two, he developed high output from his chest
tubes and was reintubated. He was taken to the operating room
where he was re-explored for bleeding and hemostasis was
acheived of a bleeding branch of a vein graft. He was then
returned to the intensive care unit for monitoring. The next
morning he awoke neurologically intact and was extubated. He
remained pacer dependent. Plavix, aspirin and a statin were
resumed. As it was unlikely his conduction system would recover,
the electrophysiology service placed a permenant pacemaker on
[**2124-8-1**] without complication. The hematology service was
consulted for thrombocytopenia. Although his HIT assay was
negative, it was recommended to treat as if he was HIT positive.
Thus, all heparin products were avoided and a serotonin release
HIT assay was sent and if positive, it is recommended he be
treated with argatroban and coumadin. His platelets recovered.
On [**2124-8-2**], he was transferred to the step down unit for further
recovery. The physical therapy service was consulted for
assistance with his postoperative strength and mobility.Plavix
was resumed. He required agressive diuresis and remained in the
hospital for diuresis.  Repeat HIT antibody was negative. SRA is
still pending. His pacemaker was interrogated on [**8-8**], adn wsa
found to be functioning correctly. He was noted to have 3 5
minute episodes of atrial fibrillation, he was switched to a
full aspirin.  He will follow up with the device clinic in 6
weeks. He was ready for discharge home on POD #12.

Medications on Admission:
Aspirin 325'
Crestor 20'
Iron 325'
MVI
Plavix 75'
Digoxin 0.25'
Lisinopril 5'
Lopressor 50"


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. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*20 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **]

Discharge Diagnosis:
CAD s/p Redo CABGx3/MVR
CHB s/p PPM
H/O CABGx6 [**1-/2124**]
CVD s/p Bilat CEA
COPD
Hyperlipidemia
HTN
AAA
PNA
MI in past
CRI
Gout


Discharge Condition:
Stable


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.
7) Call with any questions or concerns.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 2 weeks. ([**Telephone/Fax (1) 1504**]
Please call for appt.
Please follow-up with Dr. [**Last Name (STitle) 78250**] in 4 weeks.
Please follow-up with Dr. [**Known firstname **] in 6 weeks. [**Telephone/Fax (1) 78347**]
Please follow-up with the device clinic on [**9-18**] at 9:00, [**Hospital Ward Name 23**]
Building [**Location (un) 436**], [**Telephone/Fax (1) 62**].



Completed by:[**2124-8-8**]


PATIENT/TEST INFORMATION:


Indication:


Rule out tamponade
BP (mm Hg): 110/62
HR (bpm): 72
Status: Inpatient
Date/Time: [**2149-6-21**] at 08:58
Test: Portable TTE(Complete)
Doppler: Complete pulse and color flow
Contrast: None
Technical Quality: Adequate


INTERPRETATION:


Findings:


RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the
right atrium and/or right ventricle.

LEFT VENTRICLE: The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is normal (LVEF>55%).

RIGHT VENTRICLE: Right ventricular chamber size is normal.

MITRAL VALVE: The mitral valve leaflets are mildly thickened.

PERICARDIUM: There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.

GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.

Conclusions:
The left ventricular cavity size is normal. 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 is normal. The mitral valve leaflets are mildly thickened. There
is a very small pericardial effusion. There are no echocardiographic signs of
tamponade.


npn: 0700-1900
full code

mrsa, acetobacter, c-diff----strict contact precautions

all: lisinopril

picc l, 20 g hand piv

signifcant events: this am pt was difficult to arouse and minimally responsive to painful stimuli. abg suggested pt was acidoic--pt was having periods of apnea/low mv. please see carevue for am abg's. pt was taken to ct to r/o a sdh and have a chest ct. pt head was negative but chest ct showed a increase in plueral effusion. ? may be why pt was having trouble ventilating this am. pt is to have a plueral tap this afternoon/evening. since pt was placed on smiv-- abg's have improved, pt mental status has started to clear sligtly. pt has not interacted with family with gestures/mouthing words as before but has started to open eyes. cont to monitor mental status and abg's.

neuro: currently family at bedside. pt started to move right hand and open eyes spontaneously at times but pt continues to remain lethargic. pt had zyprexa/risperdal d/c'ed [**12-26**] lethargy. puplis are equal and reactive. pt is italian speaking. pt did not follow commands for this rn but has in the past. wrist rest in place [**12-26**] to hx of pulling lines and tubes.

cv: afib. with occasional pvc's. sbp 89-125/55-60. maps 55 or greater. may need metoprolol frequency changed [**12-26**] to drop in bp after dose. pt has bilateral ppp (diff to palpate). +2 pitting edema. coumadin on hold.

resp: pt was placed on a smiv this am [**12-26**] resp acidosis--apnea and low mv. pt is on a rate of 8. lungs are coarse to clear with exp wheezes heard this afternoon. pt suction q 3-4 hours for thick yellow secretions. please see carevue for abgs.

gi/gu: +bs, abd soft/obese, nontender, non distended, tf at goal. minimal residuals. foley in place, draining clear yellow urine output. gallstones since on  ct---? cholecyctitis pt is to have us this evening. tf off at this time.

skin: pt has reddness on backside of thigh--barrier cream applied. pt has duoderm intact on left hip. otherwise skin is intact.

id: abx on hold at this time except for falgyl. md's may restart other abx tonight???. tmax 100.4

social: large family. daughter in-law [**Doctor Last Name **] is the spokesperson.


Admission Note
     BABY BOY [**Known lastname 5072**] ADM TO TRIAGE FOR TACHYPNEA WITH GRUNTING, HYPOGLYCEMIA, R/O BRACHIAL PLEXUS INJURY.  ON ADMISSION INFANT IS ACTIVE BUT WITHOUT MOVEMENT OF LEFT ARM.  IS ABLE TO GRASP WITH LEFT HAND.  MARKED FACIAL BRUISING, BRUISE ALSO NOTED LEFT CHEST.  VSS, SEE FLOW SHEET. O2 SATS > 94 UNTIL FREQUENT DRIFTS NOTED AFTER 0400 FEDING.  CBC AND BLOOD CULTURES SENT AT 0630.  RARE DRIFTING NOTED AFTER LAB WORK DRAWN.  BBS COARSE INITIALLY, CLEARER NOW.  DOES HAVE STRIDOR WITH CRY. MURMUR NOTED.  PULSES NL. FEEDING ON A THREE HOUR SCHEDULE, FEEDS WELL. ONETOUCH 40-53. VOIDING AND PASSING MECONIUM.
TEMP STABLE ON OFF WARMER.  IRRITABLE WHEN DISTURBED. NO CONTACT WITH [**Name2 (NI) **].


[**2159-2-2**] 9:47 AM
 BABYGRAM (CHEST ONLY)                                           Clip # [**Clip Number (Radiology) 68446**]
 Reason: Increased oxygen requirement
 Admitting Diagnosis: NEWBORN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


Infant with RSV


REASON FOR THIS EXAMINATION:


Increased oxygen requirement
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


Severe RSV bronchiolitis with worsening O2 requirement.

 Portable chest, 9:55 a.m, [**2159-2-2**].

 Comparison is made with the study obtained 2 days earlier.

 The baby remains extubated.  NG tube enters the stomach.

 Aeration of the lungs has worsened, and there are more pronounced focal lung
 opacities in the right upper, right lower, left upper and left lower lobes.
 These findings are all likely related to hypoventilation secondary to the
 patient's severe RSV, however, superimposed consolidation due to bacterial
 pneumonia cannot be entirely excluded.

 Heart size remains stable.

 No other changes.


IMPRESSION:


Overall, worsening aeration, with new biapical and bibasilar lung
 opacities.  This was discussed with the clinical service.


[**2201-7-3**] 2:35 PM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 56890**]
 Reason: check for ptx and lung re-expansion, patient in the WPC.
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


77 year old man with right pleural effusion s/p thoracnetesis


REASON FOR THIS EXAMINATION:


check for ptx and lung re-expansion, patient in the WPC.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Right pleural effusion, status post thoracocentesis.


COMPARISON:


[**2201-6-26**].

 CHEST RADIOGRAPH, PORTABLE AP UPRIGHT VIEW:  Again noted is elevation of the
 right hemidiaphragm, similar from prior study. Unchanged small right pleural
 effusion. No effusion is noted on the left.

 There is mild atelectasis in the right base.  The cardiomediastinal and hilar
 contours are normal.  There is no pneumothorax.


IMPRESSION:


Unchanged small right pleural effusion.  No pneumothorax.


MICU NPN 7P-7A
NEURO: INITIALLY LETHARGIC BUT AROUSABLE WITH DAUGHTER IN ROOM, DIFFICULT TO UNDERSTAND. OPENING EYES AND INCONSISTENTLY FOLLOWING COMMANDS. LATER WITH BIPAP ON MORE AGITATED, PULLING AT MASK. BILAT SOFT WRIST RESTRAIINTS IN PLACE. RECEIVED 1MG HALDOL WITH MINIMAL EFFECT. LATER MUCH CALMER, AROUSABLE, UNABLE TO ASSESS ORIENTATION AS SHE IS NOT ANSWERING QUESTIONS. MOVING ALL EXTREMITIES. GAG IMPAIRED. DENIES PAIN.

CARDIAC: HR 74-102 AF WITH FREQUENT PVC'S. BP 97-140/38-69. PULSES PALPABLE AND BY DOPPLER. HCT 27.7 DOWN FROM 30.2. INR 2.3, UP FROM 2, DID NOT RECEIVE COUMADIN LAST NIGHT. NO SIGNS OF BLEEDING.

RESP: RECEIVED ON 50% COOL NEB MASK. LS WITH I/E WHEEZES. NEBS AS ORDERED. LATER CHANGED TO BIPAP 10/+5 40%. RR 20-40 WITH TV 300-400CC. VBG 7.32/75/35. RT REMOVED BIPAP AND PLACED PT BACK ON COOL NEB @70%. SATS 90-97%. LS COARSE WITH DIMINISHED BASES. CXR DONE THIS MORNING. ON PREDNISONE.

GI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. NO GI ACCESS. UOP 20-140CC/HR S/P DIURETICS. LT YELLOW AND CLEAR. CREAT 2.2.

FEN: WAS NOT REACHING GOAL OF -500CC BY END OF DAY. GIVEN EXTRA DOSE OF EDECRIN AND DIURIL BUT ONLY -100CC @2300. PERIPHERAL EDEMA PRESENT. LYTES PER CAREVUE. NPO WITH NO GI ACCESS AND UNABLE TO RECEIVE PO MEDS, MD AWARE.

ID: TMAX 95.6 WITH WBC 11.4 DOWN FROM 14.8. CONTINUES ON CEFTRIAXONE FOR UTI. CONTACT PRECAUTIONS.

SKIN: MULTIPLE ECCHYMOTIC AND HEMATOMAS ON EXTREMITIES. NO BREAKDOWN.

ACCESS: PIV X1, RIGHT BRACHIAL PICC.

SOCIAL/DISPO: DAUGHTER VISITING. DR [**Last Name (STitle) 4503**] SPOKE WITH HER TO CONFIRM STATUS. PT IS A DNR BUTWOULD BE INTUBATED. PLAN INTERMITTENT BIPAP, CONTINUED DIURESIS, WILL NEED TO PLACE DOBHOFF TUBE FOR TF'S AND MEDS.


PATIENT/TEST INFORMATION:


Indication:


Aortic valve disease. Congestive heart failure. H/O cardiac surgery.  Left ventricular function.
Height: (in) 59
Weight (lb): 112
BSA (m2): 1.44 m2
BP (mm Hg): 80/40
HR (bpm): 72
Status: Inpatient
Date/Time: [**2117-9-21**] at 22:13
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Technical Quality: Suboptimal


INTERPRETATION:


Findings:


The underlying rhythm appears to be atrial fibrillation with ventricular paced
rhythm.
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire
is seen in the RA and extending into the RV.

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal
technical quality, a focal LV wall motion abnormality cannot be fully
excluded. Low normal LVEF.

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

AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular
calcification. Mild thickening of mitral valve chordae. Calcified tips of
papillary muscles. No MS. Moderate (2+) MR. [Due to acoustic shadowing, the
severity of MR may be significantly UNDERestimated.]

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate
[[**2-7**]+] TR. Mild PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on [**2109**]
AHA endocarditis prophylaxis recommendations, the echo findings indicate a
moderate risk (prophylaxis recommended). Clinical decisions regarding the need
for prophylaxis should be based on clinical and echocardiographic data.
Emergency study performed by the cardiology fellow on call. Right pleural
effusion.

Conclusions:
Suboptimal technical quality.
The left atrium is mildly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. The gradient was not assessed and the leaflets are not
well seen. No aortic regurgitation is seen. The mitral valve leaflets and
supporting structures are thickened. At least moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery systolic
hypertension. The pulmonic valve leaflets are thickened. There is no
pericardial effusion.


IMPRESSION:


Symmetric left ventricular hypertrophy with low normal systolic
function. At least moderate mitral regurgitation. Pulmonary artery systolic
hypertension.

Based on [**2109**] AHA endocarditis prophylaxis recommendations, the echo findings
indicate a moderate risk (prophylaxis recommended). Clinical decisions
regarding the need for prophylaxis should be based on clinical and
echocardiographic data.


[**2180-11-17**] 5:33 PM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY                          Clip # [**Clip Number (Radiology) 94436**]
 Reason: ?PE
  Contrast: OPTIRAY Amt: 100
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


41 year old man with SOB s/p esophageal surgery


REASON FOR THIS EXAMINATION:


?PE
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: YGd FRI [**2180-11-17**] 6:23 PM
  No PE.  Small R effusion and bibasilar atx.  Expected post esophagectomy and
  gastric pullthrough appearance.
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


41-year-old male with shortness of breath, status post
 post-esophagectomy.  Question PE.


COMPARISON:


None available.


TECHNIQUE:


MDCT of the chest was performed prior to and following
 administration of intravenous contrast as per CTA protocol.  Multiplanar
 reformations were generated.

 CT CHEST:  The aorta is normal in caliber throughout without acute pathology.
 There is normal three-vessel arch configuration.  The main pulmonary artery is
 normal in caliber.  There is normal opacification of the pulmonary arterial
 tree, with tapering distally.  There is no lobar or segmental filling defect
 to suggest pulmonary embolism.  The heart is normal in size without
 pericardial effusion.  Patient is status post esophagectomy and neo-esophageal
 gastric pull-through with expected postsurgical appearance.  There is material
 within the neoesphagus, suggestive of mild stasis. Central airways are patent.
 A small pleural effusion is present on the right with bibasilar linear
 atelecatsis.

 Limited subdiaphragmatic evaluation demonstrates no significant visceral
 abnormality other than left upper quadrant mesenteric haziness, which is
 incompletely evaluated.

 BONE WINDOWS:  No definite focal concerning lesion.


IMPRESSION:


No evidence of pulmonary embolism.  Small right pleural effusion
 and postsurgical appearance of esophagectomy with gastric pull-through.
 (Food) material within the neoesphagus, to just above the carina suggestive of
 stasis, which may increase risk of aspiration.

 Findings reported to Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] at the time of dictation on [**2180-11-17**].

                                                             (Over)

 [**2180-11-17**] 5:33 PM
 CTA CHEST W&W/O C&RECONS, NON-CORONARY                          Clip # [**Clip Number (Radiology) 94436**]
 Reason: ?PE
  Contrast: OPTIRAY Amt: 100
 ______________________________________________________________________________


FINAL REPORT


(Cont)


Lactation Consult
Met w/ mother today to assess infant's positioning and interest in breastfeeding. Baby positioned cross cradle using a bed pillow. Suggested mom use a breastfeeding pillow for better support. Reviewed pumping goal of 8X per day. Encouraged skin to skin contact. Infant was very sleepy during this session. Will meet w/ mother by next Weds. to assess milk supply and latch.


PATIENT/TEST INFORMATION:


Indication:


?Pulmonary embolism.
Height: (in) 78
Weight (lb): 510
BSA (m2): 3.36 m2
BP (mm Hg): 98/68
HR (bpm): 107
Status: Inpatient
Date/Time: [**2128-5-1**] at 11:08
Test: Portable TTE (Focused views)
Doppler: Limited Doppler and color Doppler
Contrast: None
Technical Quality: Suboptimal


INTERPRETATION:


Findings:


LEFT ATRIUM: Moderate LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.

LEFT VENTRICLE: LV not well seen. Cannot assess LVEF.

RIGHT VENTRICLE: RV not well seen.

AORTA: Mildy dilated aortic root. Normal ascending aorta diameter.

AORTIC VALVE: ?# aortic valve leaflets. Aortic valve not well seen.

MITRAL VALVE: Mitral valve leaflets not well seen.

TRICUSPID VALVE: Tricuspid valve not well visualized.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

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

Conclusions:
The left atrium is moderately dilated. The left ventricle is not well seen.
Overall left ventricular systolic function cannot be reliably assessed. The
aortic root is mildly dilated at the sinus level. The number of aortic valve
leaflets cannot be determined. The aortic valve is not well seen. The mitral
valve leaflets are not well seen.


IMPRESSION:


Suboptimal image quality. Inconclusive study for assessment of
right or left ventricular function.


NEURO:  [** **], APPREHENSIVE. MAE ON COMMAND. FREQUENT ATTEMPTS TO TAKE OF CPAP MASK. PULLED OUT R RADIAL ALINE. SOFT HAND RESTRAINTS APPLIED. UNABLE TO GIVE PO KLONOPINE D/T NEED FOR CPAP MASK. COUGHING WITH MOUTH CARE WHEN OFF CPAP MASK. MORPHINE 2MG IV X 1 FOR C/O HEAD AND FACE DISCOMFORT FROM MASK.

PULM:  PCO2 DOWN TO 59 ON CPAP 40%, PS 15. PCO2 UP TO 70 OFF CPAP AND ON HIGH FLOW FACE MASK FOR ~ 1 HOUR.  COUGHED UP HUGE THICK DARK BROWN MUCUS PLUG OFF CPAP. LUNGS FAIRLY CLEAR.

CV: NSR WITH RARE PVC. SBP 95-120. STERNAL DSG STAPLED, SMALL AMT SEROSANGUINOUS DRAINAGE. STERNUM STABLE, NO STERNAL CLICK DETECTED. PEDAL PULSES 3+ BILATERALLY, EXTENSIVE VENOUS STASIS BILATERAL LE, CSL ON. RIJ TRIPLE LUMEN TRAUMA LINE INTACT, UNABLE TO ASPIRATE BLOOD FROM BLUE AND BROWN PORTS, FLUSHES WELL. PT PULED PUT R RADIAL ALINE. SEVERAL ATTEMPTS TO PLACE NEW ALINE UNSUCCESSFUL [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PA. ABG'S OBTAINED BY RADIAL STICK WITH DIFFICULTY.

ENDO:  Q4H HUMALOG COVERAGE OF BLD SUGARS.

GI:  ABDOMEN SOFT, + BS. NPO.

GU:  FOLEY TO CD. LASIX GTT INCREASED FROM 3MG/HR TO 5MG/HR AT 0200 TO KEEP HUO > 100CC/HR. LASIX REPLETED.

SOCIAL: NO VISITORS OR PHONE INQUIRIES.

PLAN:  CONTINUE DIURESIS, CPAP. RESTART RADIAL ALINE FOR PULMONARY MONITORING. MONITOR STERNUM STABILITY. RESTART PO MEDS.


[**2110-3-20**] 7:26 AM
 NEONATAL HEAD PORTABLE                                          Clip # [**Clip Number (Radiology) 9506**]
 Reason: TRIPLET BORN AT 30 WEEKS, RULE OUT INTRACRANIAL HEMORRHAGE OR OTHER ABNORMALITY
 Admitting Diagnosis: NEWBORN
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


Infant born at 30 weeks gestation


REASON FOR THIS EXAMINATION:


rule out intracranial hemorrhage or other abnormality
 ______________________________________________________________________________


FINAL REPORT


HEAD ULTRASOUND:

 This is our initial ultrasound on this triplet born at 30 week gestation.
 Scans through the anterior fontanelle with limited views through the mastoid
 foramen do not demonstrate any abnormalities.  Specifically there is no
 evidence of hemorrhage or ventriculomegaly.


NPN


#2  TF 120cc/k/d.  Enteral feeds currently at 100cc/k/d=24cc
Q3hrs of BM20/neosure22.  Rec'g IVF D10W with 2meq
NaCl/100cc via PIV.  DS 52, 53, and 48--IVF increased to
2.5cc/hr.  Infant bottled full bottle x1.  Mom up to BF and
infant latched and sucked on/off for 10 min.  Abd soft, +BS,
no loops.  AG 23cm.  No spits.  Max asp 2.8cc.  Voiding and
stooling guiac neg.  Wt [**2036**](+35gms).

#3  Infant nested in air mode isolette.  Sleeps quietly when
left alone.  Active and alert with cares.  Temp stable.

#4  Mom up at 9pm.  She put infant to breast with minimal
assistance.  Asking appropriate questions.  Mom to be
discharged today.  Parents do not wish to transfer infant
closer to home in [**Location (un) 119**].

#5  Infant remains under Neoblue with eye shields in place.
Bili sent this am--results pending.  Hct this am 60.7 retic
pending.


TITLE:
   Chief Complaint:
   24 Hour Events:
   -intrathecal cytarabine last night at 10pm , will receive methotrexate
   today
   -transfused one unit last night for Hct < 21
   -HIV negative
   -Lasix gtt decreased due to hypotension to 87 systolic, pt continues to
   have good UOP
   -vanco d/c
ed per ID recs and docycline started for possible mycoplasma
   hominisis that grew from sputum cx
   -decreased PSV this morning to 15/10
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Ceftazidime - [**2144-7-20**] 08:00 AM
   Ciprofloxacin - [**2144-7-22**] 12:00 PM
   Vancomycin - [**2144-7-22**] 04:00 PM
   Bactrim (SMX/TMP) - [**2144-7-22**] 04:00 PM
   Doxycycline - [**2144-7-22**] 08:16 PM
   Fluconazole - [**2144-7-22**] 11:10 PM
   Meropenem - [**2144-7-23**] 06:12 AM
   Infusions:
   Midazolam (Versed) - 3 mg/hour
   Furosemide (Lasix) - 1 mg/hour
   Fentanyl (Concentrate) - 125 mcg/hour
   Other ICU medications:
   Famotidine (Pepcid) - [**2144-7-22**] 08:00 AM
   Heparin Sodium (Prophylaxis) - [**2144-7-22**] 08:00 AM
   Furosemide (Lasix) - [**2144-7-22**] 12:00 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  [**2144-7-23**] 06:39 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 39
C (102.2
   Tcurrent: 37.8
C (100
   HR: 108 (100 - 113) bpm
   BP: 106/56(72) {87/40(57) - 129/61(80)} mmHg
   RR: 18 (8 - 35) insp/min
   SpO2: 93%
   Heart rhythm: ST (Sinus Tachycardia)
   Wgt (current): 90.8 kg (admission): 81.7 kg
   Height: 69 Inch
    CVP: 6 (2 - 13)mmHg
   Total In:
                                                                  6,070 mL
                                                                  1,494 mL
   PO:
   TF:
                                                                    644 mL
                                                                    402 mL
   IVF:
                                                                  4,875 mL
                                                                    852 mL
   Blood products:
                                                                    150 mL
                                                                    200 mL
   Total out:
                                                                  3,670 mL
                                                                  1,480 mL
   Urine:
                                                                  3,570 mL
                                                                  1,480 mL
   NG:
                                                                    100 mL
   Stool:


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


Neonatology
Remains in RA since last Friday. Comfortable appearing. Intermittent desats. Soft murmur as before. On diuril.

Wt 2580 down 5. On SC 28 at 130 cc/k/d. Takign po once per shift. Rest via gavage. Abdomen benign. Lytes to be rechecked on Thursday.;

Continue as at present. Awaiitng maturation of resp control and feeds.


TITLE:
   Chief Complaint: respiratory distress
   24 Hour Events:
   [**10-14**]:
   -HCT stable, no transfusions
   -f/u TB records
   -legionella negative
   -currently on solumedrol
   -recheck ABG
   -defer actue EGD
   -IVF with LR due to acidosis
   -monitor K+
   - pt became more anxious when given ativan for PICC line.
   - goal plateau <30;
   - unable to place A-line
   - overnight FiO2 weaned to 50% and PEEP to 12, ABG's show excellent
   PO2's, should follow gases not sats, b/c they do not appear to be
   [**Location (un) 103**] correctly
   Allergies:
   Amlodipine
   Cough;
   Last dose of Antibiotics:
   Ceftriaxone - [**2183-10-15**] 03:00 AM
   Azithromycin - [**2183-10-15**] 04:00 AM
   Infusions:
   Fentanyl - 150 mcg/hour
   Midazolam (Versed) - 3 mg/hour
   Other ICU medications:
   Lorazepam (Ativan) - [**2183-10-14**] 11:20 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  [**2183-10-15**] 07:04 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.5
C (99.5
   Tcurrent: 36.3
C (97.3
   HR: 85 (72 - 125) bpm
   BP: 108/60(71) {103/47(61) - 167/140(143)} mmHg
   RR: 16 (16 - 37) insp/min
   SpO2: 90%
   Heart rhythm: AF (Atrial Fibrillation)
   Wgt (current): 58.3 kg (admission): 59.2 kg
             Total In:
                                                                  4,098 mL
                                                                    998 mL
   PO:
             TF:
   IVF:
                                                                  4,098 mL
                                                                    998 mL
   Blood products:
   Total out:
                                                                    690 mL
                                                                    190 mL
   Urine:
                                                                    690 mL
                                                                    190 mL
   NG:
   Stool:


Admission Note
One day old 36 [**4-18**] infant girl admitted to NICU this afternoon for respiratory distress. Delivered by repeat c/s yesterday.  Please see Attending note for detailed history.  Admitted to open warmer, temp 98.6r, HR=146 RR=66 Sat=95% in RA. BP 69/33(46).  Soft murmur heard. Retracting and tachypneic with RR 60-90s. [**Hospital1 4956**] and BC drawn. IV started D10W @60cc/kg/d. Initial d/s=87. abd soft, +BS, no void or stool since admission. Started on amp and gent. CXray done.  Mom and Dad in to visit, oriented to NICU policy and procedures. Mom appropriately [**Name2 (NI) 6**]. Discussed antibiotic course, IV fluids and plan to call Mom up to breastfeed when hungry.


[**Age over 90 323**] yo women with AFib on coumadin, CHF, b/l pleural effusions,
   atelectasis.  Was admitted with floor and developed worsending
   hypoxemia.  Lasix, and respiratory status improved.  CTA showed no PE,
   LLL collapse and mediastinal LAD.  Over course of day yesterday AF with
   RVR, worsening SOB.  Transferred to ICU.  HR improved with PO
   lopressor.
   Code Status: DNR but can intubate.
   Atrial fibrillation (Afib)
   Assessment:
   I received the patient in AF with HR of 110 to 120
s. Her blood
   pressure was in the 90
s. Over the course of the night her heart rate
   went up to the 140
s to 150
s AF with blood pressure in the low 100
   . She did not receive her afternoon dose of metoprolol 75mg [**2-24**] low
   blood pressure in the 80
   Action:
       Midnight dose of metoprolol  was given.
   Response:
       Her blood pressure stayed in the low 100
       Her heart rate is AF 117-130
   Plan:
       Monitor heart rate
       Given the metoprolol. There is holding perimeters
   Hypoxemia
   Assessment:
       Patient with positive CXR on admission for PNA. Her CXR from
   yesterday sho
   Action:
   Response:
   Plan:


Respiratory Care Note
PT remains on Prong CPAP +5 FIO2 30-34%.  B.S. clear with good air entry.  As of this time without apnea or bradys noted, pt remains on caffeine.


Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details.Suctioned for mod amts thick white secretions. MDI'S given. HR-ST. Sedated with propofol. RSBI done on 0 peep/5 ips 189. Will [** **] to monitor resp status.


Sinus rhythm. Low limb lead voltage. Delayed precordial R wave progression as
recorded on the tracing of [**2162-5-20**]. No diagnostic interim change.


[**2119-8-18**] 10:06 AM
 CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE            Clip # [**Clip Number (Radiology) 106240**]
 Reason: r/o pneumonia
 Admitting Diagnosis: ASCITES, HYPOGLYCEMIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


63 year old man with cirrhosis, encephalopathy, concern for new infection


REASON FOR THIS EXAMINATION:


r/o pneumonia
 ______________________________________________________________________________


FINAL REPORT


PROCEDURE:


Chest portable AP.


REASON FOR EXAM:


Rule out pneumonia.


Findings:


The left hemodialysis catheter is unchanged with its tip in the
 right atrium. NG tube passes into the stomach and out of view. Low lung
 volumes with bilateral lower lobe atelectasis are stable.  Lungs are otherwise
 clear, cardiomediastinal silhouette is unchanged.  A TIPS stent is
 unchanged.


IMPRESSION:


Stable bilateral lower lobe atelectasis associated with low lung volumes.  No
 new consolidation or pneumothorax.


Chief Complaint:
   Shortness of breath
   HPI:
    85yoF h/o moderate AS, afib; admitted in setting of progressive
   hypoxemia and dyspnea.  She reports several days of progressive
   dyspnea, then had an acute change yesterday afternoon with worsening of
   her dyspnea.  Seen by EMS and found to be hypoxemic and placed on
   BiPAP.  Brought to ED and admitted to ICU for ongoing management.
   24 Hour Events:
   Admitted overnight and has had steady improvement in her oxygenation.
   Weaned from NRB now to 4L NC.
   Allergies:
   Lisinopril
   throat swelling
   Last dose of Antibiotics:
   Levofloxacin
   Ceftriaxone
   Oseltamivir
   Other medications:
   Colace
   Heparin
   PPI
   Simvastatin
   Insulin sliding scale
   Changes to medical and family


history:


No change
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2128-1-21**] 08:11 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 36.1
C (97
   Tcurrent: 36.1
C (97
   HR: 73 (70 - 85) bpm
   BP: 112/52(68) {99/52(64) - 126/64(75)} mmHg
   RR: 24 (20 - 26) insp/min
   SpO2: 98%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 61 Inch
             Total In:
             87 mL
   PO:
             TF:
   IVF:
   87 mL
   Blood products:
   Total out:
                                                                      0 mL
                                                                    570 mL
   Urine:
   570 mL
   NG:
   Stool:


0700-[**2070**] ADDENDUM TO NPN


RESP: Transient tacypnea noted with RR as high as 80s-90s,
M.D. aware.


[**2163-8-5**] 3:51 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 4571**]
 Reason: evaluate for interval change
 Admitting Diagnosis: PNEUMONIA
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


65 year old man with HCAP, hypoxia, chronic trach


REASON FOR THIS EXAMINATION:


evaluate for interval change
 ______________________________________________________________________________


FINAL REPORT


AP CHEST, 4:17 A.M. ON [**8-5**]


HISTORY:


Hypoxia.  Longstanding tracheostomy.


IMPRESSION:


AP chest compared to [**4-21**] through [**8-4**]:

 Bibasilar atelectasis, severe on the right and complete collapse on the left
 are unchanged accompanied by small bilateral pleural effusion.  Upper lungs
 are grossly clear, heart size is normal.  Tracheostomy tube in standard
 placement.  Left PIC line ends at the junction of brachiocephalic veins.


Sinus rhythm. Atrial ectopy. Low amplitude T waves in I, I, III, aVF and V4-V6.
INT: Non-specific T wave abnormalities. Compared to the previous tracing
of [**2130-8-19**] T wave abnormalities persist. ST segment depressions are no longer
present in the anterolateral leads and in lead II. T wave abnormalities have
improved in leads III and aVF. Resolution of ischemia.
TRACING #1


Chief Complaint:
   1. Hypotension
   2. Opioid overdose
   24 Hour Events:
   - Bolused a total of 3L NS
   - Blood cultures grew GNR
   - Cipro added to [**Last Name (un) 614**]
   History obtained from [**Hospital 15**] Medical records
   Allergies:
   History obtained from [**Hospital 15**] Medical recordsNo Known Drug Allergies
   Last dose of Antibiotics:
   Vancomycin - [**2181-6-22**] 10:30 PM
   Meropenem - [**2181-6-23**] 02:00 AM
   Ciprofloxacin - [**2181-6-23**] 03:00 AM
   Infusions:
   Other ICU medications:
   Naloxone (Narcan) - [**2181-6-22**] 11:45 PM
   Heparin Sodium (Prophylaxis) - [**2181-6-23**] 12:00 AM
   Other medications:
   OSH Meds:
   acetaminophen
   captopril 37.5 mg po tid
   clonidine patch 0.2 mg
   colchicine 0.6 mg [**Hospital1 **]
   fentanyl patch 100 mcg
   iron 325mg [**Hospital1 **]
   advair 250/50 [**Hospital1 **]
   nystatin swish and swallow
   omeprazole
   ondansetron prn
   oxycodone 20 mg q 4 hrs
   Eucerin
   imipenem/cilastatin 500 mg IV
   ipratroprium inh
   LR 62.5 ml/hr
   lido patch
   lorazapam
   metop 100 mg po tid
   mirtazapine 30 mg qhs
   nitroglycerine patch 0.2 mg/hr daily
   Changes to medical and family


history:


Review of systems is unchanged from admission except as noted below
   Review of systems:  Complaints of low-back pain.
   Flowsheet Data as of  [**2181-6-23**] 06:37 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.4
C (99.4
   Tcurrent: 36.5
C (97.7
   HR: 100 (100 - 130) bpm
   BP: 89/48(57) {78/40(49) - 123/61(75)} mmHg
   RR: 20 (20 - 29) insp/min
   SpO2: 97%
   Heart rhythm: ST (Sinus Tachycardia)
   Height: 62 Inch
             Total In:
                                                                  3,310 mL
                                                                    920 mL
   PO:
             TF:
   IVF:
                                                                  2,210 mL
                                                                    920 mL
   Blood products:
   Total out:
                                                                    195 mL
                                                                    715 mL
   Urine:
                                                                    115 mL
                                                                    345 mL
   NG:
   Stool:


Ht: 65
   Wt: 90kg
   BMI: 65kg
   PMHx: HTN
   Meds: RISS, KCl (20mEq repletion), Famotidine, Neutraphos 2 packet,
   Dilantin
   Diet: regular
   Potential for nutrition risk. Patient being monitored. Current
   intervention if any, listed below:
   41 YO female with supracellar cistern SAH s/p coiling ruptured ACOMM
   aneurysm [**8-30**].  Diet advanced from clear liquids to regular this AM.
   Patient tolerating small amount today.  Family in, encouraging
   liquids.  Remains lethargic.
   Recommendations:
   1.       Encourage po
s as tolerated
   2.       Continue lytes/BS management
   3.       Will follow up to check po intake, page if questions *[**Numeric Identifier 1867**]


S/MICU Nursing Progress Note
  Pt continues to open eyes but little tracking, she did have one moment of a few words, however not recognizable. Moving right arm, no movement on the left.
  Cardiac: hr 60-80 afib, rare PVC's BP range 140-160/70-80's telemetry D/[**Name Initial (MD) **] by MD as she is awaiting a medical bed on floors and will not go to telemetry bed.
  Respiratory: on 2 liters NC, coughing to back of her throat, suctioning with yankeur catheter.
  IV' still with triple lumen in right IJ,
  Social: family in tonight, and updated.
  Plan: awaiting floor bed. ? if evaluated for PICC line as will need vanco. DNR/DNI.


[**2129-9-24**] 12:02 PM
 CHEST (PA & LAT)                                                Clip # [**Clip Number (Radiology) 11714**]
 Reason: eval. for interval change
 Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; W/ ATRIACURE MAZE
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


76 year old woman with AS, b/l pleural effusions


REASON FOR THIS EXAMINATION:


eval. for interval change
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


76 year old, evaluate for interval change of the pleural effusion.

 This study is compared to previous examination of [**2129-9-23**]. The
 right IJ line remains in place and unchanged in position. Bilateral pleural
 effusion and compression atelectases at the lower lobes is again noted. There
 has been no significant changes in the amount of bilateral pleural effusions
 since the previous study. Post operative changes are again noted as well as
 cardiomegaly and atherosclerotic changes involving thoracic aorta.


IMPRESSION:


Bilateral pleural effusion unchanged. Cardiomegaly.


Chief Complaint:
   24 Hour Events:
 EKG - At [**2125-5-1**] 10:30 AM
 PAN CULTURE - At [**2125-5-1**] 12:01 PM
 TRANS ESOPHAGEAL ECHO - At [**2125-5-1**] 01:21 PM
 BLOOD CULTURED - At [**2125-5-2**] 12:00 AM
   -Trop 0.02->0.25->0.52- given ASA
   -given 250 cc fluid bolus x2 for BPs 70/30s
   -echo shows LVH, nl EF, inc LV filling pressures
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Vancomycin - [**2125-5-1**] 11:00 AM
   Piperacillin/Tazobactam (Zosyn) - [**2125-5-2**] 06:01 AM
   Infusions:
   Other ICU medications:
   Morphine Sulfate - [**2125-5-1**] 10:30 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  [**2125-5-2**] 07:06 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.1
C (100.6
   Tcurrent: 35.9
C (96.7
   HR: 61 (55 - 134) bpm
   BP: 93/35(49) {69/33(42) - 148/86(103)} mmHg
   RR: 22 (12 - 39) insp/min
   SpO2: 97%
   Heart rhythm: SR (Sinus Rhythm)
   Height: 60 Inch
             Total In:
                                                                  1,240 mL
                                                                    100 mL
   PO:
             TF:
   IVF:
                                                                  1,000 mL
                                                                    100 mL
   Blood products:
   Total out:
                                                                  1,282 mL
                                                                    235 mL
   Urine:
                                                                  1,282 mL
                                                                    235 mL
   NG:
   Stool:


focus hemodynmics
data: neuro: alert and oriented. moves all extremities on the bed and will attempt to assist when turning in the bed. very pleasant. ambien given for sleep and slept well. at 0500am awoke and appeared to be confused to place and time. easily reoriented.  pt stated it must of been the sleeping pill.

resp: breath sounds clear in the upper lobes and diminished inthe lower lobes. o2sat 100%. coughing but not raising any sputum.

cardiac: in normal sinus rthymn. loprssor given as ordered. heart rate down to the 50's and one time drop to the 30's but quickly up to the 50's. bp elevated to the 180's and hydralazine 10mg iv given with bp response of 140-150's.

gI stooling x2. abd obese with audible bowel sounds. taking po's well. no nausea or vomitting.

gu foley patent and draining yellow urine.

action: labs as ordered. turned q4hrs. no pain med given tonite as pt did not express any pain. right hip dsg changed for small amt of serous drainage. dry sterile dsg applied. ambien po for sleep and slept well.

respone:monitor closelyl


Nursing progress note


#3 O: Wgt up 35 gms. Remains on 140cc/k/d of SSC24. Abd soft
with active bowel sounds & no loops. No spits, minimal
aspirates. Voiding & stooling. Stool was guaiac neg. PG feed
given over 1 hr. PO feed offered at 12M. Baby took 41cc out
of total of 54. Remainder fed PG. A: Tolerating feeds &
gaining wgt. P: Cont to assess. Offer PO feed if awake.
#4 O: Temp stable swaddled & co-bedding with twin.
Occasionally wakes for feeds. [** 25**] with cares. A:
Appropriate. P: Cont to assess.
#5 O: Mom phoned for update. Mo pleased that baby is doing
well. A: Loving parent. P: Support.
#8 O: No apnea, bradycardia, or desats so far this shift. A:
Stable in room air. P: Cont to document spells.


[**2178-5-2**] 9:27 PM
 CT HEAD W/O CONTRAST                                            Clip # [**Clip Number (Radiology) 87217**]
 Reason: right hand weakness eval for CVA
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


72 year old man with


REASON FOR THIS EXAMINATION:


right hand weakness eval for CVA
 No contraindications for IV contrast
 ______________________________________________________________________________
 WET READ: SGA SAT [**2178-5-2**] 10:07 PM
  no hemorrhage or edema
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Right hand weakness.

 COMPARISONS:  None.


TECHNIQUE:


Axial non-contrast MDCT images were obtained through the head.

 CT HEAD WITHOUT IV CONTRAST:  There is no evidence of intracranial hemorrhage,
 hydrocephalus, shift of normally midline structures or edema.  The [**Doctor Last Name **]-white
 matter differentiation appears intact throughout.  There are atherosclerotic
 calcifications of the anterior and posterior circulations.  The visualized
 paranasal sinuses and mastoid air cells are well pneumatized.


IMPRESSION:


No evidence of intracranial hemorrhage or edema.

 Of note, MRI with diffusion-weighted imaging is most sensitive for evaluation
 of acute ischemia.


Atrial fibrillation with a decrease in the ventricular response as compared to
the previous tracing of [**2145-11-26**]. Lead V6 was not obtained. Right bundle-branch
block and ventricular ectopy persist. Otherwise, no change.
TRACING #2


Sinus tachycardia with premature atrial contractions and ventricular premature
beats.  Intraventricular conduction defect.  Leftward axis.  Diffuse ST-T wave
changes.  Compared to tracing #1 ventricular premature beats are seen more
commonly on the current tracing.
TRACING #2


ccu nursing progress note
pls see carevue flowsheet for complete vs/data/events

s: orally intubated
o: id: afeb. started vanco for prelim gpc in sputum. remains on unasyn.
cv: afib this am rate in the 90s. bp >100/ . this am, levo weaned off by 8:30am. pt underwent tee this am. rec'd additional sedation, 4mg versed and 50mcg fentanyl. several hours later bp trended down to 70s/ , rec'd 500cc ns bolus without response and levo was restarted around 2pm. shortly after pt had cdv, converted to sr after 200j x1. now in sr w hr 50-80. bp 85-105/50-70 via rad aline on levo at .08-.1 mcg/kg/min.
heparin held this am as ptt>150. inr was 3.8. discussed with team and heparin was restarted after being held for several hours. w hypotension discussion of possible pa line insertion ledus to again hold heparin. resend inr, now 2.7. heparin remains off at present. team would like to resend inr this eve.
resp: changed to ps 12/5. 40%. tv 400, rr 12-18. abg: 7.40/37/126/24/ 0. sxn'd for sm amt drk tan sputum. bs scatt coarse.
plan for ct of chest his eve to eval parenchyma
gi: npo. per resident cxr confirms placement of ogt in stomach. no stool.
gu: foley to [**Last Name (un) **]. uop 20-40cc/hr. cr 2.0(2.4)
skin: intact. has bitten tongue w bruising on front of tongue.
ms: when light pt is restless, moving all extremities and thrashing about. unable to focus or follow commands. sedated w versed w effect, fentanyl given w procedures today.
social: dtr here most of day. spoke w rn, sw and attending about current status and plan of care. dtr is [**Name2 (NI) **] emotional at times. husband brought her home. her numbers are in the chart and she would like to be called with any change in condition or results of scheduled procedures.

a: resp failure of unclear etiology. s/p tee and cdv, now in sr but req pressors. alt ms of unclear etiology.
p: follow hemodynamics, volume status, urine o/p. wean levophed as indicated, maintain sbp >90. follow rhythm. check inr this eve. monitor resp exam. safety precautions. med for comfort. support to pt and family.


[**2159-12-18**] 2:22 PM
 CT CHEST W/O CONTRAST                                           Clip # [**Clip Number (Radiology) 5068**]
 Reason: ? pulmonary mets
 Admitting Diagnosis: HISTORY OF JAUNDICE; BILE DUCT STRICTURE\ PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


65 year old man with with malignant neoplasm of bile duct s/p ptc on [**2159-12-17**]


REASON FOR THIS EXAMINATION:


? pulmonary mets
 No contraindications for IV contrast
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


Malignant neoplasm of the bile ducts, status post PTC on
 [**2159-12-17**].


TECHNIQUE:


Multidetector CT images of the chest were obtained without
 intravenous contrast.


COMPARISON:


No prior chest CTs are available for comparison.

 CHEST CT WITHOUT IV CONTRAST:  There are several small mediastinal lymph
 nodes, with the largest measuring 1.0 x 1.1 cm in the precarinal region.  Two
 small pulmonary opacities are present, a tiny nodule in the left upper lobe
 measuring 2 mm, and one in the right lower lobe which is irregular  in
 shape and peribronchiolar, 5 mm long. Bilateral lower lobe atelectasis is
 present.

 The patient is status post biliary drainage catheter placement.  A 1.4 x 3.1
 cm subcapsular collection of contrast material is present anterior to segment
 IV, likely sequelae of PTBD procedure.  No other extracapsular fluid
 collections are seen and there is no evidence of hemorrhage.  The osseous
 structures reveal no suspicious lytic or sclerotic lesions.


IMPRESSION:


1.  Two small pulmonary lesions, the larger, in the right lower lobe most
 likely due to local inflammation. Attention to these nodules on followup exams
 is recommended.

 2.  Borderline enlarged mediastinal lymph nodes, a nonspecific finding.


nuero: alert and oriented x3 via [** 648**] interperter. pt follows commands.

pain: pt c/o h/a, pt recieved tylenol awaiting effect.

pulm: pt lungs exp. wheezing noted in upper lobes, dimished at bases. this morning 02 saturations in 80's(please see flow sheet), pt requesting to be put back on bipap mask. pt bipap masked placed back on pt, dr. [**Last Name (STitle) **], dr. [**Last Name (STitle) **] aware. pt put back on 2lnp this afternoon pt 02 saturation 92%-98% please see flow sheet. venous abg done at 1545, dr. [**Last Name (STitle) **] aware of results. pt coughing and raising whitish secretions.

cards: pt in sr, no vea noted please see flow sheet

gi: pt tolerating clear liquids.

gu: u/o this afternoon down to 15cc/hr, dr. [**Last Name (STitle) **] called and aware, pt recieved 500 d51/2 ns bolus x1 await effect.

f/e na 148, k 3.7 tx'd with 40meq kcl.

activity: pt oob to chair with 2 assist tolerating fine.

plan: continue to monitor, monitor u/o, monitor resp. status, placed on bipap when needed, monitor na levels.


Sinus rhythm. Compared to tracing #1 precordial ST-T wave changes persist but
are less prominent.
TRACING #2


CLinical Nutrition
O:
34 wk gestational age BB, SGA w/ IUGR, now on DOL 1.
Birthwt:  1455 g (<10th %Ile)
HC:  29 cm (~10th %Ile)
LN:  41 cm (~10th to 25th %Ile)
Labs due to be drawn today
NUtrition:  80 cc/kg/day TF.  NPO, but plan to start feeds today @ 30 cc/kg/day BM/SSC 20.  PN started on DOL 0 via [** 1407**].  Remainder of fluids as PN; projected intake for next 24hrs from PN ~24 kcal/kg/day, ~1.5 g pro/kg/day; no lipids yet.  From EN:  ~20 kcal/kg/day, ~0.3 to 0.6 g pro/kg/day and ~1.1 g fat/kg/day. GIR from PN ~3.5 mg/kg/min.
GI: Abdomen benign, good bowel sounds, no stool yet.  NGT placed and some air out.

A/Goals:
Tolerating PN with good BS control.  Plan to start feeds today and monitor closely for tolerance.  Labs due to be drawn at 24 hrs of life.  Initial goal for feeds is ~150 cc/kg/day BM/SSC 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day.  Expect PN to advance as per protocol, but if feeds are well tolerated, then PN will primarily be supplemental to feeds and tapered as feeds advance towards initial goal.  Appropriate to add Fe and Vit E supps when feeds reach initial goal. Further increases in feeds as per growth and tolerance.  Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk or HC gain, and ~1 cm/wk for LN gain.  WIll follow w/ team and participate in nutrition plans.


Case Management Note
Chart reviewed and EIP & VNA options placed in record.  Clinical updates will be provided to [**Company 711**] insurance and I will assist w/any d'c planning needs along with team & famiy


[**2155-1-28**] 1:23 PM
 ART DUP EXT LO UNI;F/U                                          Clip # [**Clip Number (Radiology) 81313**]
 Reason: fem-[**Doctor Last Name 196**], graft surveillance
 ______________________________________________________________________________
 [**Hospital 3**]


MEDICAL CONDITION:


74 year old woman with


REASON FOR THIS EXAMINATION:


fem-[**Doctor Last Name 196**]
  graft surveillance
 ______________________________________________________________________________


FINAL REPORT


ARTERIAL DUPLEX LOWER EXTREMITY:

 REASON:  Patient s/p femoral-popliteal bypass graft.  Perform follow up
 surveillance.


FINDINGS:


Duplex evaluation was performed of the right SFA to tibioperoneal
 trunk bypass graft.  Peak systolic velocities in cm/sec. are as follows:  135,
 66, 58, 60 in the native proximal vessel, proximal anastomosis, distal
 anastomosis and native distal vessel respectively.  Throughout the remainder
 of the graft velocities range from 40 to 56.


IMPRESSION:


Widely patent right superficial femoral artery to tibioperoneal
 trunk bypass graft without any evidence of stenosis.


NPN 0700-1900

#1 Alt. in Resp. Function
O: Remains in NC 13-25cc 100%. RR 50's-80's with mild SC retractions. Breath sounds are clear and =. Trial of RA after sats consistantly 100 in 13cc. Lasted ~ 1 hr before sats again drifting to 80's with periodic breathing. Placed back in 13cc NC with sats presently 95-100.
A: Minimal 02 need, but still with drifting sats in RA
P: Continue close monitoring and wean to RA when able.

#2 Alt. in Nutrition
O: TF=150cc/kg=80cc BM24 Q 4 hrs. Abd. is round, soft with active BS. Occasional aspirates, mod. spit x 1. Voiding and stooling. PO fed X 2 taking 40-45cc. Gavage fed remainder.
A: Still requires gavage
P: Continue with present feeding plan and encourage POs as able. Follow daily wts.

#4 Alt. in Development
O: Maintaining temps in open crib, swaddled, positioned supine with boundraies in place. Not waking for feeds, but alert with cares. Not acting very hungry. PO fed slowly and required gavage to achieve full volume. No spells but periodic breathing evident with some drifting sats.
A: Immature feeding and breathing skills
P: Continue to support developmental needs.

#5 Alt. in Parenting
O: No contact form [**Name2 (NI) **] today.
A: Unable to assess
P: Keep informed and support.

#7 Alt. in Skin Integrity
O: Perianal area still excoriated from monilial infection. Nystatin ointment reordered and applied alternating with "old" [**Known lastname **] w/zinc oxide
A: Monilial rash with excoriation
P: Continue alternating nystatin and [**Known lastname **]. [**Month (only) 24**] need to be left open to air if w/o improvement in 24-48 hrs.


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:
   Overnight, continued to recevie fluids and remains off vasopressors.
   Continued on LR at 200 cc...
   24 Hour Events:
 EKG - At [**2111-12-29**] 03:00 AM
 FEVER - 102.4
F - [**2111-12-28**] 08:00 AM
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Metronidazole - [**2111-12-28**] 08:00 AM
   Ciprofloxacin - [**2111-12-28**] 09:00 AM
   Vancomycin - [**2111-12-28**] 08:17 PM
   Piperacillin/Tazobactam (Zosyn) - [**2111-12-29**] 09:50 AM
   Infusions:
   Midazolam (Versed) - 2 mg/hour
   Fentanyl - 50 mcg/hour
   Other ICU medications:
   Famotidine (Pepcid) - [**2111-12-28**] 05:34 PM
   Pantoprazole (Protonix) - [**2111-12-28**] 08:17 PM
   Fentanyl - [**2111-12-29**] 03:56 AM
   Midazolam (Versed) - [**2111-12-29**] 03:56 AM
   Heparin Sodium (Prophylaxis) - [**2111-12-29**] 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  [**2111-12-29**] 11:01 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37.6
C (99.7
   Tcurrent: 35.4
C (95.8
   HR: 59 (48 - 105) bpm
   BP: 97/53(70) {89/49(65) - 142/83(106)} mmHg
   RR: 13 (0 - 20) insp/min
   SpO2: 97%
   Heart rhythm: SB (Sinus Bradycardia)
   Height: 61 Inch
   CVP: 12 (10 - 15)mmHg
   Total In:
                                                                  8,134 mL
                                                                  1,701 mL
   PO:
   TF:
   IVF:
                                                                  7,409 mL
                                                                  1,701 mL
   Blood products:
                                                                    725 mL
   Total out:
                                                                  2,659 mL
                                                                    906 mL
   Urine:
                                                                  1,599 mL
                                                                    341 mL
   NG:
                                                                    140 mL
                                                                    280 mL
   Stool:


Neonatology Attending Progress Note
Now day of life 1, CA [**79**] 1/7 weeks.
Cardiorespiratory status stable in RA.
RR 30-40s HR 130-140s  BP 60/44 49

Wt. 1665gm on 80ml/kg/d via UVC with PN and IV fluids
DS - 77-95
NPO
UO 2.8ml/kg/hr passing meconium

Social - urine and mec sent for tox screen.

ID - on amp and gent, culture

Assessment/plan:
Baby continues to do very well.
Will initiate trophic feedings slowly - 20ml/kg/d for 2 days.
Nutritional support with PN.
Will schedule family meeting for later this week.
HUS planned for this week.
Social Work will continue to follow.


Chief Complaint:
   24 Hour Events:
 DIALYSIS CATHETER - STOP [**2167-2-21**] 03:15 PM
 BLOOD CULTURED - At [**2167-2-21**] 04:17 PM
 PICC LINE - STOP [**2167-2-21**] 04:23 PM
   PICC placed by IV RN. Awaiting CXR confirmation of tip placement.
   - blood grew GPCs, started on vancomycin
   - neuro wants MRI and EMG
   Allergies:
   Oxycodone
   Nausea/Vomiting
   Last dose of Antibiotics:
   Cefazolin - [**2167-2-19**] 04:00 PM
   Vancomycin - [**2167-2-21**] 11:30 AM
   Infusions:
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2167-2-22**] 06:05 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  [**2167-2-22**] 07:20 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 38.3
C (101
   Tcurrent: 38.1
C (100.6
   HR: 111 (111 - 119) bpm
   BP: 130/69(92) {102/57(73) - 159/74(103)} mmHg
   RR: 24 (21 - 31) insp/min
   SpO2: 96%
   Heart rhythm: ST (Sinus Tachycardia)
   Wgt (current): 76.5 kg (admission): 76.1 kg
   Height: 59 Inch
                  Total In:
                                                                  1,417 mL
                                                                    290 mL
   PO:
                  TF:
                                                                    963 mL
                                                                    290 mL
   IVF:
                                                                    305 mL
   Blood products:
   Total out:
                                                                      0 mL
                                                                      0 mL
   Urine:
   NG:
   Stool:


Cardiology Fellow Admit Addendum
   Please see CCU resident admit  note for complete details of HPI, PMH,
   Medications, SH/FH.
   In brief, this is a 73yoM with rheumatic heart disease causing AS/AR,
   MS/MR, atrial fibrillation, chronic lung disease, admitted to [**Hospital1 1276**] with
   dyspnea.
   On admission to [**Hospital1 5**] was briefly in the MICU, receiving steroids for
   COPD exacerbation, diuresed.  TTE results as noted in H.O. note.  Taken
   to cath lab today, where R/LHC showed elevated biventricular pressures
   and low CO/CI.
   Pt was transferred to CCU for close monitoring, with plan for TEE
   tomorrow to evaluate suitability of mitral valve for valvuloplasty vs
   surgery.
   Exam notable for stable HR in afib in the 60s, BP 100s/55s.  Breathing
   reasonably comfortable on NC.  Does not seem grossly volume overloaded
   on exam, although invasive numbers suggest otherwise.
   Impression
   73m with complex mixed valvulopathy, awaiting TEE for further
   characterization of his syndrome and suitability for corrective
   procedures.
   TEE tomorrow.
   Needs more diuresis tonight; probably will require Lasix drip.
   Heparin gtt.
   Further plans as detailed by admitting resident note.
   Case discussed with Dr. [**Last Name (STitle) **].
   [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4157**], M.D.
   x90493


Neonatology
Doing well. RA. No spells. Comfortable appearing.

ABdomen benign. Tolearting feeds well. Taking good intake.

Received HBV.
Passed car seat test.
PMD fu arranged for Monday of next week.
Dischareg summary dictated. PMD contacetd.
Plan for discharge later today.

DC prep time 35 minutes.


RESP CARE: Pt remains [** **]/on vent with settings per carevue.No ABGs this shift. Lungs- bilat rhonchi/Sxd thick white sputum from ETT/ mod amt bile colred fluid from oropharynx. RSBI 109. Plan is for ? trach/peg..


This is a 51M with HTN, OSA, morbid obesity now with acute onset of
   hypoxic hypercarbic respiratory failure and fever with leukocytosis and
   bandemia.
   Sepsis without organ dysfunction
   Assessment:
   TMAX 101.5.  Pt remains on neosynephrine drip.  BP 90-136/43-78.  HR,
   SR 80
s-90
s. no ectopy noted. One bottle BC reporting gram positive
   cocci in long chains.  CVP 11-14.  No fluid boluses this shift.
   Action:
   Tylenol and BCx1 for tempature spike.
   Response:
   Pt remained febrile with Tylenol.   Slowly able to wean neosynephrine
   down throughout the course of the day.
   Plan:
   PT started on clindamycin.  CT of abdomen with oral contrast and lower
   extremities CT to r/o necrotizing fascitis
   Pulmonary Embolism (PE), Acute
   Assessment:
   Pt remains on heparin drip currently @ 2200u/hr.  No active bleeding
   noted.  LENIs negative for DVT. +PP
   Action:
   Weaned heparin per s/s guidelines.
   Response:
   [**Name (NI) 9037**] PTT
   Plan:
   Next PTT check @21:00
   Impaired Skin Integrity
   Assessment:
   Pt has small abrasion on left lower extremity.  Rt big toe with old
   ingrown toenail site which was removed and  he was treated with
   antibxs.  Groin area noted to be red rashy and yeasty.  Per wife
   report he sometimes has that rash.
   Action:
   Nystatin powder ordered
   Response:
   No change
   Plan:
   Continue to monitor. Pt on bari maxx ii bed.
   Respiratory failure, acute (not ARDS/[**Doctor Last Name 11**])
   Assessment:
   Pt remains intubated with current settings ACx26/500/60/15.   LS
   diminished at bases.   Pt lightly sedated on fentanyl and versed.  Able
   to follow commands consistently.
   Action:
   Pt given vanco/zosyn for possible PNA.  PT tolerating Fio2 wean.
   Response:
   Improving ABG
   Plan:
   Continue to monitor.


Pt A Ox3 left side weakness and left facial droop/Left side neglect
CV-VSS TF cont at 40cc/hr taking in po with HOB 45 tol well adv activity and diet
please see flow sheet/pt stable for tx to floor
Plan for rehab


NPN


#1  Infant remains on setting of 25/7 x20 FiO2 38-45%.
Conts to be labile with sat drifts into the 70's-80's.  RR
30-60's with mild SCR.  BS clear and equal.  Suctioned for
small cloudy secretions.  Infant remains on lasix,
aldactone, and [** 772**].  No bradys.

#2  TF 130cc/k/d of BM30 with beneprotein=29cc Q4hrs on pump
over 1 1/2hrs.  And soft, +BS, no loops.  No spits.  Max asp
2cc.  Voiding, stooling loose stool guiac neg.  Wt
1805(-5gms).

#4  Infant swaddled in air mode isolette.  Weaned isolette
temp x1 during the night.  Infant active and [** **] with
cares..

#5  No contact from [**Name2 (NI) **] so far overnight.


Pertinent medications: fent gtt, versed gtt, NS @ 5ml/hr, Pantoprazole,
   Heparin, SS lytes, Colace, Lasix x1
   Labs:
   Value
   Date
   Glucose
   107 mg/dL
   [**2162-10-12**] 12:17 PM
   Glucose Finger Stick
   138
   [**2162-10-11**] 12:00 PM
   BUN
   129 mg/dL
   [**2162-10-12**] 02:13 AM
   Creatinine
   3.6 mg/dL
   [**2162-10-12**] 02:13 AM
   Sodium
   148 mEq/L
   [**2162-10-12**] 02:13 AM
   Potassium
   5.4 mEq/L
   [**2162-10-12**] 12:17 PM
   Chloride
   114 mEq/L
   [**2162-10-12**] 02:13 AM
   TCO2
   21 mEq/L
   [**2162-10-12**] 02:13 AM
   PO2 (arterial)
   108 mm Hg
   [**2162-10-12**] 12:17 PM
   PCO2 (arterial)
   36 mm Hg
   [**2162-10-12**] 12:17 PM
   pH (arterial)
   7.38 units
   [**2162-10-12**] 12:17 PM
   pH (venous)
   7.34 units
   [**2162-10-4**] 01:50 AM
   pH (urine)
   5.0 units
   [**2162-10-3**] 10:23 PM
   CO2 (Calc) arterial
   22 mEq/L
   [**2162-10-12**] 12:17 PM
   Albumin
   2.5 g/dL
   [**2162-10-12**] 02:13 AM
   Calcium non-ionized
   8.5 mg/dL
   [**2162-10-12**] 02:13 AM
   Phosphorus
   5.0 mg/dL
   [**2162-10-12**] 02:13 AM
   Ionized Calcium
   1.20 mmol/L
   [**2162-10-12**] 12:17 PM
   Magnesium
   2.9 mg/dL
   [**2162-10-12**] 02:13 AM
   ALT
   255 IU/L
   [**2162-10-12**] 02:13 AM
   Alkaline Phosphate
   524 IU/L
   [**2162-10-12**] 02:13 AM
   AST
   236 IU/L
   [**2162-10-12**] 02:13 AM
   Amylase
   15 IU/L
   [**2162-10-10**] 01:14 AM
   Total Bilirubin
   7.1 mg/dL
   [**2162-10-12**] 02:13 AM
   Triglyceride
   248 mg/dL
   [**2162-10-10**] 05:46 AM
   WBC
   10.3 K/uL
   [**2162-10-12**] 02:13 AM
   Hgb
   10.1 g/dL
   [**2162-10-12**] 02:13 AM
   Hematocrit
   30.3 %
   [**2162-10-12**] 02:13 AM
   Current diet order / nutrition support: DIET: NPO
   TF: OFF - Novasource Renal @ 42ml/hr
   GI: open, hypoactive bs; golden mucoid stool
   Assessment of Nutritional Status
   Specifics:
   Pt remains intubated/sedated.  TPN d/c
d [**10-10**] [**1-9**] TF increasing to goal
   w/ good tolerance.  TF off at this time as pt at test
 gastrograf /
   colon.  TF changed to renal formula to minimize fluid in put.  Agree w/
   renal TF formula as K, Phos and Mg are elevated. Also noted increasing
   BUN/creat.  Will need to monitor pt
s tolerance closely as new TF
   formula is not elemental (unlike Vivonex).  Noted fistula w/ thick
   yellow drainage.
   Medical Nutrition Therapy Plan - Recommend the Following
   1.       Agree w/ Novasource Renal @ 42ml/hr = 2016calories and 81g
   protein
   2.       Monitor abd exam; no residual checks w/ Jtube
   3.       Monitor fistula output
 if becomes high, may need to resume
   TPN
   4.       BS and lytes mgmt
   5.       Will continue to monitor
 page if ?s *[**Numeric Identifier 524**]
   6.       Electronically signed by [**First Name8 (NamePattern2) 419**] [**Last Name (NamePattern1) 420**], RD, LDN
   [**2162-10-12**] 15:22
   7.
   8.


19 yo M s/p MVC, reportedly pt was unrestrained front seat passenger,
   +EtOH
   Injuries:
   R temporal EDH, 15mm
   R temporal SDH, 6mm
   R temporal bone fx, comminuted, 5mm depressed
   R post/lat orbital wall fx via extension of temporal bone fx
   Pt taken to OR on [**6-3**] for right temporal and frontal craniectomy and
   evacuation of hematoma
   .
   Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)
   Assessment:
   Tmax 101.5
   Action:
   Blood cultured x1, urine culture sent, Tylenol given po
   Response:
   Temp now trending down
   Plan:
   Continue to monitor for temps and given Tylenol as needed, follow up
   with cultures, ancef as ordered, please obtain sputum specimen if pt
   able
   Trauma, s/p MVC with head trauma s/p craniectomy
   Assessment:
   Pt alert and oriented x3, lethargic but awakens easily to voice. PERRL
   Able to MAES equally and follows commands, aware of accident and
   circumstances. Reports slight headache which he rated 0.5 on a 0-10
   scale.
   Action:
   Neuro checks q1hour, Dilantin 100mg TID
   Response:
   Neuro exam unchanged with no s/s of seizure activity
   Plan:
   Continue to monitor neuro status and report changes to team


Addendum to Shift Report
Patient seen by operating Surgeon [**Doctor Last Name 10350**], discussed rehabilitation will take upwards of a week, patient will need radiation therapy to prevent regrowth of bone. Approved patient for full diet and transfer to the floor.

Patient given 10mg Diazepam (CIWA 14). Patient needs to keep Right hip straight to prevent regrowth of bone and reduce stricture.


Demographics
   Day of intubation:
   Day of mechanical ventilation: 7
   Ideal body weight: 75.3 None
   Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg
   Airway
   Airway Placement Data
   Known difficult intubation: Yes
   Procedure location:
   Reason:
   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: 42  cmH2O
                                   Cuff volume: 8  mL /
                   Airway problems:
                   Comments:
   Lung sounds
   RLL Lung Sounds: Rhonchi
   RUL Lung Sounds: Rhonchi
   LUL Lung Sounds: Rhonchi
   LLL Lung Sounds: Rhonchi
   Comments:
   Secretions
   Sputum color / consistency:  /
   Sputum source/amount:  /
   Comments:
   Ventilation Assessment
   Level of breathing assistance: Continuous invasive ventilation
   Visual assessment of breathing pattern: Gasping efforts; Comments: Pt
   reparalyzed for unusual breathing pattern.Worsening Pa02.
   Assessment of breathing comfort: No response (sleeping / sedated)
   Non-invasive ventilation assessment:
   Invasive ventilation assessment:
   Trigger work assessment:
   Dysynchrony assessment:
   Comments:
   Plan
   Next 24-48 hours: Reduce PEEP as tolerated; Comments: Reduce peep
   slowly per ABG.
   Reason for continuing current ventilatory support: Sedated / Paralyzed
   Respiratory Care Shift Procedures
   Transports:
   Destination (R/T)
   Time
   Complications
   Comments
   Bedside Procedures:
   Comments: Cont to monitor resp status.


Sinus rhythm.  Relatively short P-R interval.  Compared to tracing #1 no
change.
TRACING #2


NPN CONTINUED
RESP - PT W/ INCREASED DESATS AFTER 3AM - AT END OF FEEDING, MULTIPLE DESATS TO 50S - PT REQUIRING STIM, AND INCREASED O2 AT TIMES.  HOB^


[**2147-12-12**] 7:22 AM
 CHEST (PORTABLE AP)                                             Clip # [**Clip Number (Radiology) 35967**]
 Reason: TEMP SPIKE
 ______________________________________________________________________________
 [**Hospital 4**]


MEDICAL CONDITION:


73 year old man with ICH.
  temp spike r/o PNA


REASON FOR THIS EXAMINATION:


r/o infiltrate
 ______________________________________________________________________________


FINAL REPORT


INDICATION:


73 y/o man with intracranial hemorrhage and fever spike.


COMPARISON:


[**2147-12-10**].

 PORTABLE SUPINE AP CHEST: The ETT, NG tube, and right subclavian line remain
 in stable and satisfactory position. There are low lung volumes. The
 cardiomediastinal silhouette is stable. There is no consolidation, CHF, or
 effusion.


IMPRESSION:


No evidence of pneumonia.


Chief Complaint: respiratory failure requiring BIPAP
   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:
   68M with ESRD on HD, chronic bl pulm infiltrates associated with
   hypoxemia (never biopsied), chronic aspiration, very sensitive to
   opiates.  Got fentanyl for tunneled line (placed [**4-21**]) and developed
   hypercarbic respiratory failure. Placed on BIPAP and stabilized. Given
   narcan x 2 which improved alertness and respiratory drive. Remains
   sleepy.  Has required IVF for hypotension.  DNR/DNI.
   24 Hour Events:
   ABG 7.30|58|71 yesterday evening
   Pulled off BIPAP overnight.
   Allergies:
   Dicloxacillin
   Rash;
   Mercaptopurine
   Neutropenia; Th
   Last dose of Antibiotics:
   Meropenem - [**2175-4-21**] 05:25 PM (day 13/14)
   Micafungin - [**2175-4-21**] 08:14 PM (months)
   Infusions:
   Other ICU medications:
   Heparin Sodium (Prophylaxis) - [**2175-4-21**] 10:25 PM
   Other medications:
   mertazipine
   synthroid
   albuterol
   Heparin sc
   Protonix -> d/c
   Testosterone patch
   albumin x1 pre-HD
   synthroid
   Changes to medical and family


history:


Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2175-4-22**] 07:33 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 36.8
C (98.2
   Tcurrent: 36.8
C (98.2
   HR: 101 (83 - 101) bpm
   BP: 123/57(72) {98/38(53) - 125/66(100)} mmHg
   RR: 24 (18 - 30) insp/min
   SpO2: 100% on 4L NC
   Heart rhythm: SR (Sinus Rhythm)
   Height: 72 Inch
             Total In:
                                                                  2,450 mL
                                                                    705 mL
   PO:
             TF:
   IVF:
                                                                    440 mL
                                                                     76 mL
   Blood products:
   Total out:
                                                                      0 mL
                                                                      0 mL
   Urine:
   NG:
   Stool:


[**Last Name (LF) **],[**First Name3 (LF) **] A.                     ORTHO TSICU                [**2100-11-16**]  2:22 PM
 CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN          [**Name Initial (PRE) 7**] # [**Clip Number (Radiology) 92760**]
 Reason: s/p left subclavian line placement and reevaluate for worsen
 Admitting Diagnosis: T7 FX
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


28 year old man with new line placement and chest tubes bilaterally. please do
  XRAY at 1430. Thank you


REASON FOR THIS EXAMINATION:


s/p left subclavian line placement and reevaluate for worsening pneumothoraces
  bilaterally
 ______________________________________________________________________________
                                  PFI REPORT
 PFI:  Intubated, unchanged position, left subclavian line in good position.
 Chest tubes remain, no new pneumothorax has developed.


PRE MEDICATED C TYLENOL AND BENEDRYL. WHEN BLOOD READY RUN FIRST 2 UNITS OVER 2 HRS EA THEN DRAW BLOOD.


[**2171-5-5**] 11:34 PM
 CHEST PORT. LINE PLACEMENT                                      Clip # [**Clip Number (Radiology) 68978**]
 Reason: eval line
 ______________________________________________________________________________
 [**Hospital 2**]


MEDICAL CONDITION:


[**Age over 90 **] year old woman with s/p line


REASON FOR THIS EXAMINATION:


eval line
 ______________________________________________________________________________


FINAL REPORT


HISTORY:


[**Age over 90 **]-year-old female status post line placement.


COMPARISON:


Portable chest radiograph performed earlier on the same evening
 [**2171-5-5**] at 10:10 p.m.

 PORTABLE UPRIGHT CHEST RADIOGRAPH:  Since the study of 1.5 hours prior, there
 has been interval placement of a right internal jugular central venous
 catheter, the tip of which is likely located at the superior cavoatrial
 junction.  No new pneumothorax, mediastinal widening is seen.  Cardiac
 enlargement with right pleural effusion and atelectasis and possible tiny left
 pleural effusion is unchanged.  Again right lower lung consolidation cannot be
 excluded.


IMPRESSION:


Right internal jugular central venous catheter tip terminates in
 the region of the superior cavoatrial junction.


