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Classify the following medical document.
|
TITLE: CCU Progress Note
Chief Complaint:
24 Hour Events:
- No overnight events
- Comfortable on room air.
- Requesting to go home
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2124-3-9**] 07:11 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.9
C (98.4
Tcurrent: 36.8
C (98.2
HR: 75 (75 - 93) bpm
BP: 96/46(58) {84/44(55) - 103/58(69)} mmHg
RR: 22 (17 - 34) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
PO:
TF:
IVF:
Blood products:
Total out:
530 mL
295 mL
Urine:
530 mL
295 mL
NG:
Stool:
Drains:
Balance:
-530 mL
-295 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///31/
Physical Examination
Gen: WDWN elderly male in NAD, appears younger than stated age.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP elevated to earlobe
CV: RR, 3/6 systolic murmur LUSB raditaing to carotids. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to halfway B/L.
Speaking in full sentences.
Abd: Soft, NTND. No HSM or tenderness.
Ext: 2 pitting edema B/L.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Labs / Radiology
1.3 mg/dL
31 mEq/L
3.9 mEq/L
34 mg/dL
100 mEq/L
139 mEq/L
[image002.jpg]
[**2124-3-8**] 10:33 PM
Cr
1.3
TropT
0.02
Other labs: CK / CKMB / Troponin-T:31//0.02, Mg++:2.0 mg/dL
Assessment and Plan
The patient is a [**Age over 90 **] year-old male with a PMH of CAD, moderate AS, and
COPD admitted with acute onset dyspnea.
.
#. Acute on Chronic Systolic and Diastolic CHF - The patient presents
with acute onset dyspnea, similar to prior admissions, differential
diagnosis includes acute diastolic CHF vs COPD exacerbation. Patients
symptoms most likely secondary to CHF exacerbation given evidence of
volume overload on exam and CXR. BNP elevated though decreased from
prior. The patient has no evidence of CE elevation or new ischemic ECG
changes. He likley has episodes of transient ischemia leading to
acute-on-chronic diastolic dysfunction and pulmonary edema as described
prior. The patient also reports brief feeling of "chest spasm" relieved
with neb in ED, suggests possible component of reactive airway disease.
No wheezing on exam currently.
- Trend CE, negative x2 so far
- Continue lasix IV, goal 1L negative today
- Continue lisinopril and metoprolol
- Continue nebs PRN
- Hold on further abx/steroids for now. There appears to be a possible
RLL infiltrate that we will followup with PA and lateral chest xray.
.
#. Coronary Artery Disease - s/p BMS to OM2, D1, Left circumflex in
[**2122-11-16**] for unstable angina - pt has declined further attempts at
revascularization. No current acute ischemic changes on ECG
- Trend CE, negative x2 so far
- Continue ASA, metoprolol and lisinopril
- Goal HCT ~30 given history of ischemia
.
#. Moderate Aortic Stenosis - careful diuresis given increased preload
dependence
- BB and ACE-I as above
.
# Gout: On allopurinol. Started cholchicine at home dose as needed
#. COPD
Will start tiotropium for likely COPD. Outpatient PFTs
.
#. Chronic GI Bleeds - Pt has had GIB in past on plavix, monitor HCT
.
#. FEN - cardiac diet, replete lytes PRN
.
#. Access: PIV
.
#. PPx: heparin SC
.
#. Code: FULL
.
#. Dispo: Floor today
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2124-3-8**] 06:50 PM
Prophylaxis:
DVT: Heparin SQ
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
------ Protected Section ------
Cardiology Teaching Physician Note
On this day I saw, examined and was physically present with the
resident / fellow for the key portions of the services provided. I
agree with the above note and plans.
I would add the following remarks:
History
Nothing to add, agree with above
Physical Examination
Nothing to add, agree with above
Medical Decision Making
Nothing to add, agree with above
Total time spent on patient care: 30 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 4646**] [**Name (NI) **] on:[**2124-3-11**]
08:28 ------
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2178-10-24**] Discharge Date: [**2178-10-30**]
Date of Birth: [**2135-7-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug-eluting stent placement in LAD
x 2
History of Present Illness:
Patient is a 43 year-old male with HTN, Family Hx of CAD, and
Tobacco use who had episode of persistent chest pain after work
2 days PTA. States sharp substernal chest pressure going from
throat to the esophagus. no radiation, no associated sob,
denies n/v/d. Pain constant never relieved and pt came to the
ED ~ 36 hours after the onset of pain.
.
In the [**Name (NI) **] pt noted to have ST elevations anterolaterally and
tachycardic, given IV lopressor and sent to cath lab.
.
On cath found to have proximal occlusion of LAD ->[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, CI
1.86 -> IABP placed and pt transferred to CCU. Pain free post
cath. On admission to CCU pt had no complaints.
ROS: +some doe for months, denies pnd/orthopnea/syncope.
+Palpitations.
Past Medical History:
1. HTN
2. Anxiety
3. Psoriasis
Social History:
Smoker 15 pack year history. Lives in [**Location **], social etOH,
programmer at [**Hospital1 112**].
Family History:
Mother died of MI at 69, Father - CVA, 2 sisters with MI, DM, 2
brother with DM.
Physical Exam:
GEN: Middle aged man in NAD
HEENT: PERRL, MMM, JVP ~9cm at 30degrees.
CHEST: CTAB anteriorly and laterally.
CVR: RRR, nl s1, s2, no r/m/g
ABD: Soft, nt, nd
EXT: no edema, 2+ dp/pt pulses bilaterally. Groin site with
soft hematoma, arterial line in place.
Neuro: CNI-XII intact, A&O X 3.
Skin: bilateral white plaques on forarms consistent with
psoriasis.
Pertinent Results:
CBC: 15.3/44.2/331
Diff, N:79.6 L:15.0 M:4.5 E:0.5 Bas:0.5
Chemistry: 137/3.8/97/25/14/1.0/174
CK: 287 MB: 7 Trop-*T*: 2.43
PT: 13.2 PTT: 25.1 INR: 1.2
.
DATA:
ECG presentation: ST at 142, [**Apartment Address(1) 25947**],L, V1-V5. (V2-V4 >5mm).
ECG post cath: ST at 100, ST normalized in 1,l,v1. STE V2 2mm,
v3-V4 3mm.
Cath - CO 3.24, CI 1.83, PCW 21, RA 10, PA 32/17, RV 32/8.
LMCA - nl,
LAD occluded at its origin, diag with thrombus and stenosis at
its origin. dilation and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**]. residual 80% with normal
flow.
LCX - normal.
RCA - normal
.
ECHO
The left ventricular cavity size is top normal/borderline
dilated. There is
moderate regional left ventricular systolic dysfunction. Overall
left
ventricular systolic function is moderately depressed. Resting
regional wall
motion abnormalities include anteroseptal, anterior
hypokinesis/akinesis and
apical akinesis/dyskinesis. Right ventricular chamber size and
free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There
is no pericardial effusion. No apical thrombus seen (cannot
exclude).
.
CATH
Initial angiography showed a proximally occluded LAD.
We planned to recanalize the vessel. Eptifibatide was continued.
A 6
French XBLAD3.5 guide provided good support. The lesion was
crossed with
great difficulties using a Choice PT wire, which was then
exchanged for
a Prowater wire. Thrombectomy was performed using an Export
catheter.
The lesion was then pre-dilated with a 2.0 mm balloon at 8 atm.
Next,
two overlapping 3.0x3 mm and 3.0x28 mm Cypher DES were deployed
in the
mid and proximal LAD at 14 atm. Post-dilation was performed with
a
3.25x23 mm Highsail balloon at 16 atm. Angiography showed slow
flow in
D1, which was rescued with a 2.0 mm ACE balloon at 8 atm. Final
angiography showed no residual stenosis in the LAD, some
thrombus in D1
with an 80% resdual stenosis, no dissection and TIMI 3 flow in
both
vessels. The patient left the lab in stable condition.
* COMMENTS: 1. Selective coronary angiography in this right
dominant
patient revealed severe single vessel CAD. The RCA was
angiographically
normal. The Left Main and LCX were also both angiographically
normal.
The LAD was completely occluded at its origin. The D1 also had
thrombus and stenosis at its origin
2. Resting hemodynamics revealed mild RA pressure elevation of
10mmHG.
The pulmonary pressures were slightly elevated at 32/17 and the
PCWP was
moderately elevated to 21mmHG consistent with abnormal diastolic
function. The cardiac index was depressed at 1.83 l/min/m2.
3. Successful stenting of the LAD with two 3.0 mm Cypher
drug-eluting
stents, which were post-dilated to 3.25 mm.
4. Successful insertion of a 40 cc IABP with good diastolic
augmentation.
Brief Hospital Course:
Patient is a 43 year-old male with HTN, smoking history, Family
Hx of CAD who presented with anterolateral ST elevations and
found to have proximal occlusion of LAD in the cath lab. The
following issues were addressed during his hospital stay:
1. Cardiovascular
A. Coronary Artery Disease: Given complete proximal LAD
occlusion in cath lab, 2 DES were placed in the artery with
significant improvement in blood flow. Patient tolerated
procedure well. An intra-aortic balloon pump was also placed in
the cath lab with good diastolic augmentation. Patient received
integrillin drip for 18 hours post-cath. Also started on
ASA/Plavix/Statin/ACEI. BB was started prior to discharge, and
medications were titrated up as tolerated. Patient was evaluated
by Physical Therapy and cleared for discharge home with
recommendations for cardiac rehabilitation.
B. Pump: At cath, CO 3.24, CI 1.86. An IABP was placed at cath
for afterload reduction and better coronary perfusion. This was
discontinued the following day. LVEDP was 21 on cath, however
post-cath patient voided 450cc without any lasix. ECHO showed EF
35%, anterospetal, anterior hypokinesis/akinesis, apical
akinesis/dyskinesis, with no overt apical thrombus visualized.
Given apical akinesis, patient was started on Coumadin and
bridged with heparin until therapeutic INR was achieved.
C. Rhythm: Patient in sinus rhythm, with initial tachycardia of
multifactorial etiology: fever, acute coronary syndrome,
dehydration, and poor EF with compensatory tachycardia to
maintain cardiac output. Patient's HR began to decrease
gradually post-MI, with fever resolution and improved cardiac
function. No significant events were noted on telemetry.
Patient to follow-up with Electrophysiology in 1 month for ICD
placement evaluation.
2. FEVER
Patient developed fever of unclear etiology post-MI; UA, CXR
negative. 1 set blood cultures with gram positive cocci
clusters/pairs, coagulase negative, likley contaminant given
clinical picture. Other work-up was negative, and fever curve
trended down without antibiotic therapy. Impression was fever
secondary to acute myocardial infarction and cytokine release.
Patient was without evidence of leukocytosis, and was afebrile x
48h prior to discharge without Tylenol administration.
.
3. HTN
Patient initially with asymptomatic relative hypotension
initially, which resolved with cardiac revascularization and
gentle fluid boluses. Patient discharged on Toprol XL 50 and
Lisinopril 5, to follow-up in [**Hospital 191**] clinic for further control.
.
4. PSORIASIS
Patient with bilateral psoriatic plaques over arms, back, legs.
No acute issues as inpatient, to be followed as outpatient.
.
5. HEME
Blood bank contact[**Name (NI) **] team as patient with [**Name (NI) 25948**] antibody on
Type and Screen, usually seen in patients with history of
transfusion. Patient denies any history of blood product
transfusion. Labs not consistent with hemolysis; haptoglobin
350s, adjusted retic count WNL (LDH cannot be used as marker
given recent infarction)
Patient reportedly with sickle cell trait, nothing to work-up
further as inpatient.
.
6. Prophylaxis
Patient on heparin gtt while being bridged to Coumadin. Patient
ambulating, had BM while inpatient.
Medications on Admission:
Paxil 10mg qd.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*3*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*4*
4. Paroxetine HCl 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please have your INR checked; dose may be adjusted accordingly.
Disp:*30 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*6*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*6*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO As directed by a
physician: [**Name10 (NameIs) **] is an extra prescription to be used pending any
changes in your Coumadin dosage. .
Disp:*60 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please have your INR drawn by VNA on Saturday and have results
called to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital3 **] on [**11-2**] -
Monday A.M. -- [**Telephone/Fax (1) 250**] (INR does not need require f/u over
weekend)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
1. Acute ST Elevation MI s/p 2 DES to LAD
Secondary
1. HTN
2. Hyperlipidemia
3. Tobacco use
Discharge Condition:
chest-pain free, hemodynamically stable, afebrile
Discharge Instructions:
1. Please take all medications as prescribed -- Aspirin and
Plavix MUST be taken daily.
2. Among your new medications, you have been started on
Coumadin. This requires frequent visits for lab draws. Please
make sure the results are sent to your PCP so that necessary
dose adjustments can be made.
3. Please make all follow-up appointments.
4. Please refrain from any strenuous activity including heavy
lifting for the next few weeks and until cleared by a
cardiologist.
5. Please stop smoking
6. You will need to begin cardiac rehabilitation in 1 month -
please arrange this with your PCP [**Name Initial (PRE) **]/or cardiologist.
Followup Instructions:
The following appointments have been schedule for you:
1. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-11-2**] 11:30 (To have your INR checked) -- [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 895**], North Suite
2. Provider: [**Name10 (NameIs) 640**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-11-11**]
2:30
(To establish new PCP) - [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 895**]
3. Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2178-11-17**] 1:00, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
4. Electrophysiology (evaluation for ICD placement). Dr. [**Last Name (STitle) **],
Friday, [**2184-12-3**]:00 AM. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 3971**]
Completed by:[**2178-11-2**]
|
Discharge summary
|
Classify the following medical document.
|
micu npn 1900-0700
patient received at 1900 from am shift. micu team had finished putting in r subclavian quad lumen. cxr showing that it was not in the correct position. dr [**Last Name (STitle) **] coming down to assist in rewiring line. cxr done and line ok per resident samone [**Doctor Last Name **]. r ij line pulled and i sent the tip for culture and switched over his lines to the new subclavian. within a half an hour dr [**Last Name (STitle) **] informed me that his line needed to be rewired again d/t incorrect positioning. i accessed his groin dialysis line fro propofol and the ambisone that he had begun to receive. dr. [**Last Name (STitle) **] and dr. [**Last Name (STitle) **] placed a new quad lumen in the r ij that has been confirmed by cxr to be in the correcr position. his line have been switched back over to this new line.
systenms review-
neuro- patient remains sedated on 30 mcg/kg/[**Last Name (STitle) 217**] of propofol. he opens eyes and awakens to voivem inconsistantly follows some simple commands, not able to get him to nod his head to yes/no q's though.
cv- vasopressin off ~12am with last line change, bp had been in the 120 sys map 70's range. within a half hour, the intern, dr [**Last Name (STitle) **], pulled the subclavian line and pt's bp began to fall to the mid 80 sys range maps 50-60. vasopressin restarted at previous dose of 0.04 u/[**Last Name (STitle) 217**]. also within this time. pt had previously not had any ectopy, he began to have 4-7 beat runs of vtach, which all spontaneously resoved. after the line was placed a chem 10 was sent off revealing a K of 2.9 and mg of 1.6. the pt received 40 meq kcl and 3 amps mg. am labs to be drawn shortlky will reflect this. hr 60-70's o/n, sbp remains 95-100 on vasopressin.
resp- remains on a/c .4 fio2 peep 10 750x14, occ breathing 1-2 breaths above, sats 98-100%, no abg's ordered this shift. suctioning tan thick sputum via ett q4-5 hrs.
gi/gu- tube feeds (deliver 2.0( continue at 30 cc/hr, to up rate to 40 at 6am, [**Last Name (STitle) **] to advance SLOWLY -- q12 hrs to goal of 50cc/hr. viokase begun to assist in absorbtion of tube feeds d/t pt's hx of pancreatic insufficiency. pt conts w/large amts of stool (1300cc) o/n to mushroom catheter, slightly ob+ this am. sm amts brown urine to foley.
endo- insulin gtt off xseveral hrs while access was an issue. [**Last Name (STitle) **] titrating blood sugars q1-2 hrs, currently at 0.5 u/hr bs in the 80;'s.
id- a febrile o/n. vasopressin back on ?volume depletion w/lg stool losses and dialysis x2 days in a row w/good fluid removal both days. vs. new sepsis s/p pulling line out.. conts on ambisone q24 hrs for yeast n blood cultures from [**2163-8-31**].
heme- conts to have [**Last Name (un) 374**] low platelets, hit+, now pt w/new lij, subclavian clots, pt written to begin on lipirudin for anticoagulation, held o/n d/t r dialysis line needing to be pulled tonight or more likely in the am..
skin- multiple issues,, see flowsheet for details. much improved rash from uremia of last week. now pt w/yeast to groin, back, arm pits.. treating w/miconizole powder.
[**Last Name (un) **] to support on vent until ms [**First Name (Titles) 7959**] [**Last Name (Titles) **] ready to begin weaning.. vasopressin for maps >60, attempt to turn off a
|
Nursing/other
|
Classify the following medical document.
|
Admission Date: [**2159-9-18**] Discharge Date: [**2159-9-20**]
Date of Birth: [**2084-12-10**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p right carotid angiography and stenting
Major Surgical or Invasive Procedure:
Right carotid angiography and stenting
History of Present Illness:
74M hx of L ICA stenosis (s/p CEA [**2159-6-26**]), 80% R ICA stenosis,
CAD s/p CABG ([**2154**], anatomy unavailable), EF 60%, prior CVA (no
residual deficits), PAF (On Coumadin), HTN, HL, DMII, Moderate
to Severe PVD, that presents to CCU following right carotid
angiography and stenting.
.
The pt was referred to Dr. [**Last Name (STitle) **] on [**2159-4-28**] for evaluation of
PVD. The pt subsequently underwent stress nuclear perfusion (no
anginal symptoms or ischemic EKG changes). Non-Invasive vascular
studies revealed non-compressible vessels and moderate to
moderately severe peripheral vascular disease at rest based on
Doppler waveforms and PVR??????s. ABI??????s invalid due to non
compressibility of vessels. Given the pts known carotid bruits,
the pt underwent Carotid U/S that showed significant bilateral
carotid stenosis, L>R. Angiography ([**2159-6-25**]) revealed an 80%
stenosis of the [**Country **] (which supplies the left ACA) and a 99%
[**Doctor First Name 3098**] stenosis. Cerebral angiography further revealed patent
right ACA and MCA and patent left ACA and left MCA. He did have
a recent event when he was unable to move his left leg for a
couple of days, but slowly regained function.
.
Thus the pt underwent L CEA on [**2159-6-26**]. Of note during the
admission for ([**2159-6-25**] thru [**2159-6-28**]) the pt tolerated the
procedure well. On POD 1 he experienced a severe headache that
did resolve and was consistent with symptoms of reperfusion
postop. The pt was kept in the VICU overnight for observation.
The pt also experienced increased neck stiffness at that time.
The pt also had LE swelling US without DVT. Subsequent Carotid
U/S ([**2159-7-19**]) revealed stable R ICA stensosis 70-79%
(unchanged). Left side without residual stenosis at CEA site.
.
Upon further review of symptoms the pt reports + Occasional
dizziness, no prior syncope, occasional HA, Denies CP/SOB. No
sensory or motor defects. The pt also noted a history of "ill
defined feeling" in both legs with exercise that occasionaly
occurs with rest. The pt previously attributed this to prior SVG
harvest. He recalls that he might have had a stroke 10-15 years
ago (unclear) without any residual deficit. Prior to CABG, he
only had diaphoresis.
.
Further review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
In general, the patient tolerated the procedure well. He had a
vagal reaction during the procedure which required atropine.
His SBP then went up to the 200s requiring a nitro drip. Access
was first attempted in the right arm, but was unsuccessful.
Therefore a right femoral approach as used. He was transferred
to the CCU with an SBP of 100 off of the nitro drip for close
monitoring of his blood pressures with a goal SBP between 90 and
120. He had a headache after the procedure which resolved by
the time he was transferred to the CCU.
Past Medical History:
Paroxysmal atrial fibrillation
CAD s/p CABG in [**2154**] ([**Hospital1 112**])
Prior CVA
Bilateral carotid artery disease
Anemia
PVD
Hypertension
Diabetes c/b retinopathy and peripheral neuropathy
Cataracts s/p surgery
Thyroid nodule
Colon polyps s/p resection
Intermittent Lower back pain
Proteinuria
s/p right elbow fracture as a child
Arthritis
Social History:
Patient is married with two children
Lives with: Wife
Occupation: previously worked as a printer
ETOH: none
Family History:
No family history of premature CAD
Physical Exam:
VS: T=36.4 BP=91/44 HR=51 RR=14 O2 sat=100% RA
GENERAL: pleasant male in NAD. Alert and oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Left> right crackles at
the bases. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. RUE bandage is c/d/i.
RLE has some oozing at the cath site, no hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Warm
and well perfused with normal capillary refill time. 1+ Left
and trace right lower leg edema.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP, PT [**Name (NI) **]
[**Name (NI) 2325**]: Carotid 2+ Femoral 2+ Popliteal 1+ DP, PT [**Name (NI) **]
Pertinent Results:
Cardiac Cath ([**9-18**])-
1. Access was initially obtained at the right brachial artery.
Due to
anatomic tortuosity, we changed our approach and obtained access
from
the right femoral artery.
2. Selective angiography of the right carotid artery showed an
80%
stenosis at the bifurcation of the ICA and ECA extending
distally into
the proximal segment of the ICA.
3. Successful PTA and placement of an 8.0x29mm self-expanding
Carotid
Wallstent were performed. The stent was post-dilated using a
5.0mm
balloon. (See PTA comments.)
4. The right common femoral arteriotomy was successfully closed
using a
Perclose Proglide device.
.
FINAL DIAGNOSIS:
1. Right carotid artery disease.
2. Successful placement of a stent in the CCA-ICA.
3. The primary operator for this procedure was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
The primary assistant was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
[**2159-9-19**] 06:40AM BLOOD WBC-8.1 RBC-2.95* Hgb-8.2* Hct-25.5*
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.0 Plt Ct-220
[**2159-9-19**] 02:05PM BLOOD WBC-8.0 RBC-2.81* Hgb-8.0* Hct-24.5*
MCV-87 MCH-28.4 MCHC-32.5 RDW-14.3 Plt Ct-185
[**2159-9-18**] 09:00AM BLOOD PT-14.1* PTT-33.6 INR(PT)-1.2*
[**2159-9-19**] 06:40AM BLOOD PT-13.4 PTT-31.1 INR(PT)-1.1
[**2159-9-19**] 06:40AM BLOOD Glucose-58* UreaN-32* Creat-2.0* Na-134
K-4.3 Cl-100 HCO3-24 AnGap-14
[**2159-9-19**] 02:05PM BLOOD Glucose-215* UreaN-32* Creat-2.1* Na-130*
K-4.5 Cl-98 HCO3-23 AnGap-14
[**2159-9-19**] 02:05PM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9
Brief Hospital Course:
74 y/o male with severe PVD, CABG in [**2154**], CVA with no residual
effect, and bilateral carotid artery disease s/p left CEA [**7-3**]
presenting for right carotid stenting.
.
# s/p RCA Stenting: Pt enrolled in [**Last Name (un) 81078**] study, underwent RCA
stenting. Patient had a vagal reaction during the procedure
which required atropine. His SBP then went up to the 200s
requiring a nitro drip. Otherwise he tolerated the procedure
well and was transferred to the CCU with an SBP of 100 off the
nitro drip. While in the CCU, our goal remained SBP 90-120.
Patient stayed in the 100s-120s. Neuro exam performed q1h for 2
hours, q2h for 2 checks, and then q6h after the procedure - all
were within normal limits. Post-cath check at 2:30PM showed
some R femoral oozing, but no hematoma or bruit. Patient's heart
rate was 40s-50s s/p procedure, asymptomatic. His beta blocker
was held in this setting; resumption will be addressed by his
PCP. [**Name10 (NameIs) **] will go home on [**Doctor Last Name **] of Hearts monitor to
continually monitor heart rate for 2 weeks. Patient's home dose
of ASA 325mg and Plavix 75mg continued after procedure.
Coumadin 5mg resumed after the procedure and lovenox
administered twice daily dosing until INR became therapeutic.
Patient will go home with 5 days of lovenox as bridge. INR will
be checked on [**9-24**].
.
# CORONARIES: previous CABG. Last stress-MIBI without concerning
ECG changes. Continued home ASA, Plavix, Statin, Beta-Blocker,
[**Last Name (un) **]. Patient denied any chest pain while in hospital. No EKG
changes noted.
.
# PUMP: Last EF 60%. Initially had elevated BP's post-procedure.
Trended down to SBP 100s-120s. Switched home atenolol 150mg
daily to metoprolol 75mg [**Hospital1 **] for rate control given slightly
increased creatinine. Upon discharge, BP was 110s-120s and HR
was 50s, 60s with ambulation. Patient stable.
.
# RHYTHM: Pt with hx of PAF, currently bradycardic sinus rhythm.
Continued to stay in bradycardic rhythm at HR 45-50s.
Discharged on [**Doctor Last Name **] of Hearts monitor for 2 weeks, as noted
above. Will transmit 2-3 times daily.
.
# DMII: Patient not on insulin as outpatient. HbA1C 7.3 ([**4-2**]).
Gave home dose of glipizide and then covered to Humalog SS while
in house. Held home metformin while in-hospital. Restarted
upon discharge.
.
# Anemia: Unclear etiology. There is a longstanding history
from prior records. Previous ferritin was normal. No
microcytosis. Mildly elevated creatinine. Hemoglobin
Electropheresis WNL (+FM hx for anemia). Hct baseline ranges
from 25-30. Ranged between 24.5-31.5 while in hospital.
Consider outpatient work-up.
.
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Simvastatin 40mg Daily
Atenolol 150mg PO Daily
Irbesartan 300mg daily
Coumadin 2mg daily, 2 tablets as directed, last dose [**2159-9-13**]
Lovenox b.i.d. on [**2159-9-16**] and [**2159-9-17**]
Furosemide 40mg daily
Glipizide 10mg twice a day
Metformin 850mg three times a day
Iron-Docusate Sodium 150mg-100mg one tablet twice a day
Milk of Magnesia PRN
Foltx one tablet daily
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Iron with Stool Softener 150 (50)-100 mg Tablet Sustained
Release Sig: One (1) Tablet Sustained Release PO twice a day.
10. Foltx 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day.
11. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours) for 5 doses.
Disp:*5 syringes* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
start once your INR is between [**2-27**]. Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
right sided carotid stenosis s/p stent placement
.
Secondary diagnoses:
- s/p CABG
- HTN
- dyslipidemia
- PAF (On Coumadin)
- Prior CVA [**60**]-15 years ago (No residual defects)
- Bilateral carotid artery disease s/p left CEA [**2159-6-26**]
- Anemia (Unknown Etiology)
- PVD
- DMII c/b retinopathy and peripheral neuropathy
- Cataracts s/p surgery
- Thyroid nodule
- Colon polyps s/p resection
- Intermittent Lower Back Pain
- Proteinuria
- s/p right elbow fracture as a child
- Arthritis
Discharge Condition:
Good, vital signs stable, ambulatory
Discharge Instructions:
You were admitted to the hospital to undergo a carotid stent
placement to relieve a blockage in your carotid vessel. The
procedure went well however you developed a low heart rate
afterwards. Because of this you were admitted to the CCU for
close monitoring. While you were in the CCU, your heart rate
remained stable and you were asymptomatic. You will go home
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to continually monitor your heart
rate at home.
.
The following medication changes were made:
1. Stop your beta-blocker (atenolol 150mg).
2. Take lovenox 100mg daily for 5 days (day 1- [**9-20**]) or at least
until your Coumadin level (INR) is between [**2-27**].
3. Take Coumadin 5mg daily for 5 doses or until your INR is
between [**2-27**] and then you can go back to your home dose of
Coumadin 2mg daily.
4. You need to get your INR levels checked on [**9-22**] to monitor
your blood thinning levels.
.
Please follow-up with all of your outpatient medical
appointments listed below.
.
Please seek medical care if you experience any concerning
symptoms such as headache, dizziness, lightheadedness, decreased
muscle strength, chest pain, or increased shortness of breath.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below.
1. Follow-up with your [**Hospital 263**] clinic ([**Hospital1 **]-[**Location (un) **]) for INR check on
Saturday, [**9-22**] (If your INR is between [**2-27**] then you can stop
Lovenox, if it is below 2, continue with Lovenox).
2. Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2159-10-2**] 10:10
3. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2159-10-19**] 2:20
4. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2159-11-7**] 11:15
Completed by:[**2159-9-20**]
|
Discharge summary
|
Classify the following medical document.
|
TITLE: [**Hospital Unit Name 10**] Resident Progress Note
Chief Complaint:
24 Hour Events:
- off neosynephrine, only on levophed
- checking daily LFTs and amylase/lipase as is s/p ERCP
- Echo results [**8-22**] showed hyperdynamic LV, EF >75%, mild LVH, no
focal wall motion abnormality
- CVP was 22 based on femoral line
- [**Hospital1 966**] accepted her for transfer
- Got CVVH in preparation for transfer and for afternoon K of 6.1,
decreased to 4.9 after CVVH
- [**Hospital1 966**] decided they don't have space for her until [**1-10**], but they did
tell us that she has antiphospholipid sydrome and she was started on
heparin gtt
Allergies:
Ace Inhibitors
Unknown;
Levaquin (Oral) (Levofloxacin)
Unknown;
Cephalosporins
Unknown;
Oxycodone
Unknown;
Percocet (Oral) (Oxycodone Hcl/Acetaminophen)
Unknown;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2194-1-8**] 06:00 AM
Meropenem - [**2194-1-9**] 03:43 PM
Linezolid - [**2194-1-9**] 10:03 PM
Gentamicin - [**2194-1-10**] 06:31 AM
Infusions:
Fentanyl - 25 mcg/hour
Norepinephrine - 0.03 mcg/Kg/min
Midazolam (Versed) - 1 mg/hour
Heparin Sodium - 1,050 units/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2194-1-9**] 03:42 PM
Pantoprazole (Protonix) - [**2194-1-9**] 04:24 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 [**2194-1-10**] 07:26 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.7
C (98
Tcurrent: 36.5
C (97.7
HR: 75 (62 - 85) bpm
BP: 107/65(79) {91/54(66) - 117/78(89)} mmHg
RR: 19 (15 - 33) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 84.4 kg (admission): 74 kg
Height: 67 Inch
CVP: 24 (20 - 34)mmHg
Total In:
3,877 mL
312 mL
PO:
TF:
IVF:
3,737 mL
312 mL
Blood products:
Total out:
1,026 mL
104 mL
Urine:
NG:
500 mL
Stool:
Drains:
Balance:
2,851 mL
208 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 360 (360 - 360) mL
Vt (Spontaneous): 153 (153 - 153) mL
RR (Set): 16
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 74
PIP: 22 cmH2O
Plateau: 22 cmH2O
Compliance: 21.2 cmH2O/mL
SpO2: 98%
ABG: 7.32/43/164/24/-3
Ve: 5.7 L/min
PaO2 / FiO2: 410
Physical Examination
GENERAL: cushingoid AAF, intubated and sedated
HEENT: b/l injected conjunctiva, b/l chemosis. No scleral icterus. MM
lubricated.
Neck: unable to assess JVP 2/2 habitus. tunneled line in place
CARDIAC: Regular tachycardia, 2/6 systolic murmur across precordium
LUNGS: coarse breath sounds, no crackles or wheezes
ABDOMEN: obese and surgically scarred abdomen. Minimal BS. NABS.
EXTREMITIES: cool, no edema, dopplerable dorsalis pedis/ posterior
tibial pulses. RUE old AV fistula without thrill/bruit
SKIN: No rashes/lesions, ecchymoses.
Labs / Radiology
105 K/uL
12.7 g/dL
126 mg/dL
5.0 mg/dL
24 mEq/L
4.9 mEq/L
37 mg/dL
109 mEq/L
147 mEq/L
41.7 %
8.4 K/uL
[image002.jpg]
[**2194-1-9**] 02:29 AM
[**2194-1-9**] 05:53 AM
[**2194-1-9**] 12:29 PM
[**2194-1-9**] 12:42 PM
[**2194-1-9**] 03:19 PM
[**2194-1-9**] 05:44 PM
[**2194-1-9**] 06:22 PM
[**2194-1-10**] 12:00 AM
[**2194-1-10**] 12:07 AM
[**2194-1-10**] 02:29 AM
WBC
8.3
8.4
Hct
41.5
41.7
Plt
110
105
Cr
6.5
6.7
5.0
5.0
TCO2
22
21
19
23
23
Glucose
198
144
119
126
Other labs: PT / PTT / INR:14.7/150.0/1.3, CK / CKMB /
Troponin-T:/8/0.45, ALT / AST:227/51, Alk Phos / T Bili:162/0.4,
Amylase / Lipase:53/32, Differential-Neuts:94.2 %, Lymph:3.6 %,
Mono:2.1 %, Eos:0.1 %, Lactic Acid:2.0 mmol/L, Albumin:3.3 g/dL,
LDH:212 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:5.9 mg/dL
Blood cultures 11/25 and [**1-9**] NGTD
Sputum [**1-8**]
GRAM STAIN (Final [**2194-1-8**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
Assessment and Plan
49F with SLE on chronic steroids, ESRD on HD, ERCP earlier today for
choledocholithiasis, who presented with sepsis and pancreatitis.
.
#. Sepsis - probable biliary source but DDX includes line infection.
Has h/o multidrug resistant organisms at [**Hospital1 966**].
-- f/u blood cultures (and those from [**Hospital1 1504**] ER)
-- continue meropenem/getamicin/linezolid for broad coverage
-- prn fluid for CVP goal [**9-25**], will check femoral line CVP, will also
check delta pulse pressure
-- wean vasopressors for MAP > 65
-- continue stress dose steroids for now
-- f/u ERCP c/s recs
-- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] c/s recs
-- will get echo to assess heart function with all these fluids, check
OSH records for any previous TTe
.
#. Resp Failure - Was intubated for airway protection, never dropped
saturations or demonstrated problems with oxygenation. She has evidence
of volume overload on CXR, will need aggressive IVF for sepsis and
pancreatitis management, so this will be a barrier to extubation in the
future.
-- wean FiO2 as tolerated, keep on AC for now
-- ultimately, volume management will be via HD/CVVH
-- send sputum cultures
-- fent/midaz for sedation
.
#. Pancreatitis s/p ERCP - no evidence of persistent obstruction or
free air on CT scan. However, pancreatic enzymes are elevated, and HCT
acutely elevated c/w pancreatitis.
-- aggressive IVF
-- NPO with bowel rest for now
-- pain control with IV fentanyl
-- trend LFTs and panc enzymes daily
-- ERCP to follow
.
#. ESRD
-- should be dialyzed today, will touch base with renal team
-- can likely do hemodialysis but if BP drops, may need CVVH
-- renally dose all medications
.
#. SLE
-- currently on stress dose steroids, replacing her home dose
-- continue Plaquenil 200mg daily
-- continue Bactrim SS daily for prophylaxis
.
# h/o PE - on despite ESRD [**3-18**] "coumadin resistence"
-- holding lovenox for now, will clarify coagulation needs by getting
OSH records
ICU Care
Nutrition: NPO for now given pancreatitis, but prefer early intiation
of TF's via OGT when possible, will obtain nutrition c/s
Glycemic Control: Added ISS
Lines:
Dialysis Catheter - [**2194-1-8**] 05:42 AM
Arterial Line - [**2194-1-8**] 06:33 AM
Multi Lumen - [**2194-1-8**] 03:18 PM
Prophylaxis:
DVT: Sc heparin/pneumoboots
Stress ulcer:
VAP:
Comments: Bowel regimen colace/senna
Communication: Comments:
Code status: Full code
Disposition: [**Hospital Unit Name 10**]
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint: Hypoxia
HPI:
This is a 45 year old Armenian female transferred from the BMT service
with worsening hypoxia. She was in her usual state of health until mid
[**Month (only) 93**], she began to have fevers, chills, nightsweats. This was
accompanied by a non-productive cough, nasal congestion, and fevers to
104. She was seen at [**Hospital3 **] ED and was found to have a WBC of 115
with 7% blasts, 45% bands, 15% neutrophils, 5% lymphs, 3%
promyelocytes, 14% myelocytes with LDH 1661, uric acid 4.2, Hct 23.3,
plat 28,000. She had O2 sats in the 80s on RA and was given CTX and
levaquin. She had a BM biopsy at the time the results for which were
inconclusive and she was transferred to the [**Hospital1 1**] for possible
leukopharesis. She was started empirically on vancomycin, cefepime,
levofloxacin and tamiflu. She had a CT chest that showed diffuse
ground glass opacities with airspace opacification in RML and bilateral
bases, as well as central lymph node enlargement and splenomegaly. She
was started on hydroxyurea for her initial WBC 120,000 and her WBC has
improved today to 32,000. Bone marrow bx here suggestive of acute
myeloid leukemia, cytogenetics pending. Despite broad antibiotic
coverage, her O2 requirement began to increase and micafungin was added
empirically yesterday for fungal coverage. This afternoon MICU
evaluation was requested due to worsening hypoxia with O2 sat 90% on
50% FM. She was given lasix 10 mg IV with ~1.5L urine output. ABG
revealed respiratory alakalosis with concomittant metabolic alkalosis.
Bicarb gtt was discontinued to improve metabolic alkalosis. She was
noted to have a temperature of 104 and standing tylenol was ordered.
She underwent a repeat CT thorax that revealed worsening widespread
ground glass opacities in the lungs bilaterally, with airspace
opacities in the lung bases, right middle lobe, and lingula. Due to
lack of improvement in respiratory status, and also with plans to
initiate chemotherapy for presumed component of infiltrative leukemia
adding to worsening respiratory status, she was transferred to the
[**Hospital Unit Name 10**].
.
In the [**Hospital Unit Name 10**], she reports a productive cough with yellow sputum with
blood streaks. She reports that her breathing has been gradually worse
over the last few days.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Vancomycin - [**2153-8-11**] 07:38 PM
Levofloxacin - [**2153-8-11**] 09:52 PM
Cefipime - [**2153-8-11**] 11:34 PM
Infusions:
Other ICU medications:
Other medications:
Medications at time of transfer:
Atrovent 1 neb Q6H
Albuterol 1 neb Q6H
Tylenol 650 mg Q6H
Allopurinol 300 daily
Micafungin 100 mg
Cefepime 2 gm Q8h
Vancomycin 1 gm Q12H
Levofloxacin 750 mg IV daily
Tamiflu 75 PO BID
Past medical history:
Family history:
Social History:
Rheumatic fever c/b arthralgias
Mother with history of breast cancer, father with history of throat
cancer.
She moved to US from [**Country 7525**] 7 years ago. Russian is her native
language. She also speaks English. Married. 2 sons, age 15 and 20,
works as a health aid. 25 pack year smoking history, quit 9 days ago.
Review of systems:
Flowsheet Data as of [**2153-8-12**] 12:07 AM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 39.2
C (102.6
Tcurrent: 37
C (98.6
HR: 99 (99 - 137) bpm
BP: 116/63(81) {116/63(81) - 122/67(84)} mmHg
RR: 24 (24 - 40) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
CVP: 8 (8 - 12)mmHg
Total In:
1,060 mL
27 mL
PO:
TF:
IVF:
780 mL
15 mL
Blood products:
280 mL
13 mL
Total out:
1,410 mL
160 mL
Urine:
1,410 mL
160 mL
NG:
Stool:
Drains:
Balance:
-350 mL
-133 mL
Respiratory
O2 Delivery Device: Aerosol-cool
SpO2: 97%
ABG: 7.46/43/92.[**Numeric Identifier 641**]/24/5
PaO2 / FiO2: 93
Physical Examination
Vitals: T: 102.6 BP:122/60 P: 75 R: 38 O2: 92% 100% FM
General: Sleeping but arousable, shallow breathing, oriented x 3
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP ~12 cm, no LAD
Lungs: Diffuse crackles R>L
CV: Tachycardic, nl s1 s2, [**2-16**] non-radiating soft systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Labs / Radiology
32 K/uL
6.8 g/dL
123 mg/dL
0.8 mg/dL
11 mg/dL
24 mEq/L
100 mEq/L
3.9 mEq/L
137 mEq/L
20.8 %
42.7 K/uL
[image002.jpg]
[**2150-1-12**]
2:33 A8/1/[**2153**] 07:48 PM
[**2150-1-16**]
10:20 P8/1/[**2153**] 10:21 PM
[**2150-1-17**]
1:20 P8/1/[**2153**] 11:35 PM
[**2150-1-18**]
11:50 P
[**2150-1-19**]
1:20 A
[**2150-1-20**]
7:20 P
1//11/006
1:23 P
[**2150-2-12**]
1:20 P
[**2150-2-12**]
11:20 P
[**2150-2-12**]
4:20 P
WBC
42.7
Hct
20.8
Plt
13
32
Cr
0.8
TC02
32
Glucose
123
Other labs: PT / PTT / INR:16.2/31.5/1.4, ALT / AST:34/25, Alk Phos / T
Bili:263/0.8, D-dimer:4687 ng/mL, Fibrinogen:541 mg/dL, Lactic Acid:1.2
mmol/L, Albumin:3.2 g/dL, LDH:559 IU/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,
PO4:3.5 mg/dL
Assessment and Plan
This is a 45 year old female presenting with new diagnosis of likely
AML now with worsening hypoxia, fever and diffuse interstitial
infiltrates on CT.
.
# Hypoxemic respiratory distress: Pt with underlying emphysema
compounding current picture. With interval progression of intersitial
pattern on CT scan and worsening O2 requirement. Differential includes
infectious etiologies (viral/bacterial including superimposing
nosocomial infection given that she is now day #4 of hospitalization).
Given progression despite broad spectrum coverage, infiltrative
leukemia is also on differential.
- Trial of diuresis with CVP goal < 10
- Check BNP, consider repeat ECHO if elevated
- Continue broad spectrum coverage including vanc, cefepime, levoflox,
micafungin and tamiflu.
- Will add empiric anaerobic coverage with flagyl given recent emesis
and worsening respiratory status
- Follow up culture data
- Frequent ABGs, trial of non-invasive ventilation if persistent O2
requirement/evidence of CO2 retention [**2-12**] fatigue
- Chemotherapy per oncology
- Nebs prn
.
# Fever: Currently meets SIRS criteria with temperature, HR, RR, and
WBC. Remains hemodynamically stable, cultures negative to date.
Clinical picture is compounded leukemia which may be responsible for
the above.
- f/u culture data
- Antibiotics as above
- Chemotherapy per oncology
- ATC tylenol for fever given tachycardia, increase in metabolic demand
.
# Leukemia: With likely AML, awaiting cytogentics. Plan to start
idarubacin and cytarabine tonight.
- Dexamethasone, idarubacin, cytarabine per heme onc
- TLS, DIC labs q6 hours
- Transfuse to hct >24, plt> 15K
- IVF with NS
.
# FEN: No IVF, replete electrolytes, regular diet
.
# Prophylaxis: p-boots
.
# Access: peripherals, RIJ, a-line
.
# Code: full
.
# Communication: Patient
.
# Disposition: pending above
.
ICU Care
Nutrition:NPO
Glycemic Control: n/a
Lines:
Multi Lumen - [**2153-8-11**] 05:46 PM
Arterial Line - [**2153-8-11**] 11:13 PM
Prophylaxis:
DVT: p-boots
Stress ulcer: n/a
VAP: n/a
Comments:
Communication: Comments:
Code status: Full code
Disposition: pending improvement
|
Physician
|
Classify the following medical document.
|
Mr. [**Known firstname 20**] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in [**2136**],
chronic AFib with V-pacing, chronic systolic CHF with EF 20%, multiple
recent admission to the CCU for ICD firing, readmitted from [**Hospital **]
rehab for left sided chest pain. He reports that he had severe left
sided chest pain, worse with inspiration and palpation. He denies any
dyspnea, nausea, vomiting, abdominal pain, diaphoresis, left arm or jaw
pain or any other complaints. He does not know if his ICD fired. Of
note he has been admitted numerous times recently for VT and ICD firing
due to sustained VT. During his recent admission from [**9-19**] -[**9-21**] he was
bolused with IV amiodarone twice for episodes of VT during the
admission. During that admission he continued to refuse VT ablation
and turning off ICD.
This admission pt again had VT and this time agreed to go for VT
ablation, dtr was on vacation and not reachable. Pt tolerated procedure
well, sheaths pulled last night at 8 PM, area of right groin is
slightly eccyhmotic in the inguinal area, and he also has bruises on
the ABD area. Distal pulses palpable.
Ventricular tachycardia, sustained
Assessment:
s/p ablation [**9-22**] remains, AV-paced w occasional to rare PVC
s noted. Hr
50-60earlier then MD [**First Name (Titles) 9311**] [**Last Name (Titles) 4129**] rate to 70 for improved cardiac
output. NO further runs of VT Post ablation. Lido off yesterday. Cont
on PO amiodarone. SBP 100-110 w map
s > 60 . PT does complain of off
and on Chest pain or burning and stomach upset. Team aware and they
believe pain to be R/T procedure and pt was given one percocet with
good effect. Pt, per family somewhat confused after percocet, because
he forgot that his niece was here earlier. However He can be difficult
to assess as he speaks mostly Russian and translating by family. Later
seemed more oriented, pt requested that I talk to the doctors at the
rehab, because he was not sleeping well there and maybe I could
get a sleeping pill ordered.
Action:
Monitored groin, site stable .
Response:
Remains hemodynamically stable post ablation
Plan:
Continue to follow.
Heart failure (CHF), Systolic, Chronic
Assessment:
Received lasix in lab yesterday and again this AM 120 mg IV.
Action:
Received lasix in lab and again this AM 120 mg IV.
Response:
Good diuresis after lasix putting out one liter so far today
Plan:
Cont per order, of note Mag was 6 this AM spoke to team we will redraw,
likely that
Level is due to labs being drawn from IV where Mag was running. We
will recheck at one thirty with next lab draw
Impaired Skin Integrity
Assessment:
Pt bruises easily, eccymotic areas on belly from Sub Cut heparin shots
and the area around procedure site ( right inguinal area, ) also bruise
on left wrist, ? old inflate on last admission , area 2x2 and pink.
Marked. Also left wrist bruise ? from A line attempt
Action:
All areas cleaned with soap and water, LOTA, marked
Response:
No advancement of bruises and areas skin remains intact
Plan:
Turn frequently lotion to all areas .
RISK for fall
Assessment:
Pt at times confused, language barrier, BKA , has not tried to get out
of bed today.
Action:
Exit alarm on, interpreter family members have reiterated that pt will
stay in bed and not get OOB without assistance, check on pt frequently,
offer water and toileting.
Response:
Pt did not try to get OOB today.
Plan:
Exit alarm on, interpreter family members have reiterated that pt will
stay in bed and not get OOB without assistance, check on pt frequently,
offer water and toileting.
Demographics
Attending MD:
[**Doctor Last Name **] [**Doctor Last Name 2562**] I.
Admit diagnosis:
VTACH
Code status:
DNR / DNI
Height:
Admission weight:
78 kg
Daily weight:
78.7 kg
Allergies/Reactions:
Morphine
Nausea/Vomiting
Mirtazapine
Unknown;
Ambien (Oral) (Zolpidem Tartrate)
nightmares;
Precautions:
PMH:
CV-PMH: Angina, Arrhythmias, CAD, MI, Pacemaker
Additional history: MI X2 (inferior and anteroseptal)
- CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 609**] [**2136**])
- Afib w/o anticoag (fall risk)
- Sustained VTach in [**2146**] s/p admission
- PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to
[**Company 1994**] Concerto in [**2145**].
- legally blind secondary to glaucoma
- Hiatal hernia
- Hepatic cysts/hemangioma and lipoma in hepatic flexure
- s/p Lt BKA (WWII trauma [**2078**])
- BPH s/p suprapubic prostatectomy ([**2131**])
- s/p cholecystectomy ([**2110**])
- Chronic low back pain
- Osteoarthritis
- Positive PPD in past
- Depression and anxiety
**former oncology md-[**Country **].
Surgery / Procedure and date: s/p cabg
Latest Vital Signs and I/O
Non-invasive BP:
S:109
D:59
Temperature:
98.6
Arterial BP:
S:132
D:56
Respiratory rate:
21 insp/min
Heart Rate:
72 bpm
Heart rhythm:
AV Paced
O2 delivery device:
Nasal cannula
O2 saturation:
97% %
O2 flow:
2 L/min
FiO2 set:
24h total in:
956 mL
24h total out:
2,760 mL
Pertinent Lab Results:
Sodium:
133 mEq/L
[**2147-9-23**] 06:07 AM
Potassium:
4.5 mEq/L
[**2147-9-23**] 02:03 PM
Chloride:
100 mEq/L
[**2147-9-23**] 06:07 AM
CO2:
25 mEq/L
[**2147-9-23**] 06:07 AM
BUN:
18 mg/dL
[**2147-9-23**] 06:07 AM
Creatinine:
1.0 mg/dL
[**2147-9-23**] 06:07 AM
Glucose:
90 mg/dL
[**2147-9-23**] 06:07 AM
Hematocrit:
38.9 %
[**2147-9-23**] 06:07 AM
Finger Stick Glucose:
177
[**2147-9-23**] 04:30 PM
Valuables / Signature
Patient valuables: teeth in moth dentures- eye drops
Other valuables:
Clothes: Sent home with:
Wallet / Money:
No money / wallet
Cash / Credit cards sent home with:
Jewelry:
Transferred from: ccu
Transferred to: [**Hospital Ward Name **] 3
Date & time of Transfer:
|
Nursing
|
Classify the following medical document.
|
Admission Date: [**2137-9-11**] Discharge Date: [**2137-9-14**]
Date of Birth: [**2062-9-1**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy with cauterization of duodenal ulcer
History of Present Illness:
75 year old man on ASA and Plavix for history of CVA, hx of
tobacco and EtOH abuse presented to his PCP with one week of
melena and increased stool output. He has had small dark
stools, epigastric discomfort, and decreased appetite for ~1
week. His stool output had increased from 1 BD /day to [**1-22**] then
several days PTA had constipation. He also endorsed LH, denied
N/V, CP/SOB. Later that night, lab called PCP that pt had hct
20. Pt was sent to [**Hospital1 18**] ED where he had negative NG lavage.
EGD showed an actively oozing duodenal ulcera in posterior bulb.
It was injected with epinephrine and cauterized. Upon arrival at
ED, his hematocrit was 19.3. He received 2 liters of NS and
total 6 units of PRBC with increased in hct to 33. He was
initially admitted to the MICU for observation overnight then
transferred to the floor with stable HCT.
Past Medical History:
CVA x 3 with blindness in right eye
Hypercholesterolemia
Heavy alcohol use
Social History:
Drinks 3-4 glasses of wine or beer per day and quit smoking 4
days ago. 60 pack year history. Lives with wife and is a retired
shoemaker who once worked in [**Country 651**]. Originally from Stuttgard.
Has one daughter.
Physical Exam:
T98.1 BP 123/76 (107-150/70-81) HR 80 (80-90) 16 98%RA
GEN WDWN elderly man, lying flat in bed, comfortable
HEENT [**Last Name (LF) 12476**], [**First Name3 (LF) 13775**], EOMI, 2+carotid, R bruit, JVP ~[**10-1**] @45' o/p
clear, MM dry
CV faint heart sounds, nl S1 + S2, no M/R/G noted
Pulm bibasilar crackles L>R, ~[**Date range (1) 23119**] from base
Abd +BS, mild distension, mild tenderness in hypogastrum, no
rebound
tenderness
EXT No edema, 2+DP
Neuro CN2-12 grossly intact
Pertinent Results:
[**2137-9-11**] 05:00AM
WBC-17.3* HCT-19.3* MCV-97 MCH-32.8* MCHC-33.9 RDW-17.2* PLT
COUNT-246
NEUTS-81.2* LYMPHS-13.6* MONOS-4.1 EOS-0.6 BASOS-0.5
[**2137-9-11**] 05:00AM CK(CPK)-77 CK-MB-3 cTropnT-<0.01
[**2137-9-11**] 07:18PM CK(CPK)-71 CK-MB-NotDone cTropnT-<0.01
[**2137-9-11**] 01:50PM HCT-21.7*
[**2137-9-11**] 07:18PM HCT-22.5*
[**2137-9-11**] 09:28PM HCT-23.4*
Brief Hospital Course:
1. Duodenal ulcer
After cauterization by EGD and transfusion of 6u PRBC, his hct
remained stable at 33 and he had no further episodes of melena
or frequent BM. Serology for H. pylori was positive and he was
started on clarithromycin and amoxicillin x 14 days in addition
to protonix [**Hospital1 **]. His ASA and plavix were discontinued and the
patient was asked to address with his primary care doctor when
he should begin taking these.
2. Anemia
Iron studies were consistent with iron deficiency anemia. He was
started on iron daily. In addition he was given B12, folate, and
MVI though these levels were normal, given his alcoholism.
3. EtOH use
He was placed on CIWA scale with Diazepam, which he did not
require. He was given MVI, thiamine, and folate as mentioned.
4. h/o CVA
He has had 3 strokes in the past, but per patient he had a
negative work up. He continued statin. While the ASA and plavix
were held, it is likely he needs to be placed back on these
medications for this significant CVA history; this will be
determined by his PCP as an outpatient.
Medications on Admission:
ASA 325 mg po qd
Plavix 75 mg po qd
Atorvastatin 10 mg po qd
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
7. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer
Upper gastrointestinal bleed
Blood loss anemia
Helicobacter Pylori infection
History of stroke x 3
Discharge Condition:
Stable
Discharge Instructions:
You have a duodenal ulcer. You are being given medicine to help
reduce your gastric secretions to allow this to heal. You have
also tested positive for H. Pylori, a bacteria that can
contribute to ulcers, and will need to take a course of
antibiotics to treat this. Call your doctor for any new blood in
your stool, diarrhea, dark black stools, lightheadedness, or
fatigue.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**]
[**Telephone/Fax (1) 2936**], to make a follow up appointment within the next
1-2 weeks. He should discuss with you the risks and benefits of
restarting aspirin and plavix to prevent further strokes given
your ulcer and gastrointestinal bleeding.
|
Discharge summary
|
Classify the following medical document.
|
TSICU
HPI:
66F with hx of [**Hospital 1571**] transferred from [**Location (un) 78**] after having
worst HA of life at 4p while at church. She denied N/V, CP, SOB,
LOC. Was found to have SAH at OSH, Dilantin loaded and started on
Nimodipine. She was then transferred here for further evaluation.
Chief complaint:
SAH W/ ANEURYSM
PMHx:
HTN, GERD
Current medications:
1. 2. 3. 1000 mL NS 4. Acetaminophen 5. Acetaminophen-Caff-Butalbital
6. Bisacodyl 7. Calcium Gluconate
8. Docusate Sodium 9. HYDROmorphone (Dilaudid) 10. Heparin 11.
HydrALAzine 12. Insulin 13. Magnesium Sulfate
14. Metoprolol Tartrate 15. Neutra-Phos 16. Nimodipine 17. Omeprazole
18. Ondansetron 19. OxycoDONE (Immediate Release)
20. Oxycodone-Acetaminophen 21. Phenytoin 22. Pneumococcal Vac
Polyvalent 23. Potassium Chloride
24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush
27. Valsartan
24 Hour Events:
[**5-10**]: complaints of headache, dilaudid dose increased, recieved dose of
lopressor x1
Post operative day:
POD#4 - IR- Coiling x 3
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Hydralazine - [**2175-5-10**] 05:09 PM
Hydromorphone (Dilaudid) - [**2175-5-10**] 05:30 PM
Metoprolol - [**2175-5-10**] 05:40 PM
Heparin Sodium (Prophylaxis) - [**2175-5-10**] 08:17 PM
Other medications:
Flowsheet Data as of [**2175-5-11**] 05:56 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**77**] a.m.
Tmax: 37.9
C (100.3
T current: 37.5
C (99.5
HR: 81 (65 - 92) bpm
BP: 171/67(94) {141/40(60) - 209/90(116)} mmHg
RR: 17 (11 - 21) insp/min
SPO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 126 kg (admission): 125.9 kg
Height: 67 Inch
Total In:
1,400 mL
PO:
1,400 mL
Tube feeding:
IV Fluid:
Blood products:
Total out:
5,420 mL
450 mL
Urine:
5,420 mL
450 mL
NG:
Stool:
Drains:
Balance:
-4,020 mL
-450 mL
Respiratory support
O2 Delivery Device: None
SPO2: 95%
ABG: ///25/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral : )
Abdominal: Soft, Non-distended, Non-tender, Obese
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
336 K/uL
11.8 g/dL
133 mg/dL
0.5 mg/dL
25 mEq/L
3.2 mEq/L
9 mg/dL
100 mEq/L
135 mEq/L
34.0 %
13.7 K/uL
[image002.jpg]
[**2175-5-6**] 11:57 PM
[**2175-5-7**] 02:00 AM
[**2175-5-8**] 01:37 AM
[**2175-5-9**] 02:13 AM
[**2175-5-9**] 02:07 PM
[**2175-5-10**] 01:49 AM
[**2175-5-11**] 03:40 AM
WBC
7.8
9.9
10.9
18.8
12.4
13.6
13.7
Hct
36.9
33.0
32.9
33.7
33.8
32.3
34.0
Plt
[**Telephone/Fax (3) 6029**]35
293
287
336
Creatinine
0.7
0.7
0.7
0.5
0.6
0.5
0.5
Troponin T
<0.01
Glucose
172
160
146
131
179
146
133
Other labs: PT / PTT / INR:12.6/23.2/1.1, CK / CK-MB / Troponin
T:32/2/<0.01, Differential-Neuts:82.8 %, Lymph:13.5 %, Mono:3.5 %,
Eos:0.0 %, Albumin:4.0 g/dL, Ca:8.3 mg/dL, Mg:2.2 mg/dL, PO4:2.1 mg/dL
Assessment and Plan
AEROBIC CAPACITY / ENDURANCE, IMPAIRED, BALANCE, IMPAIRED,
HYPERTENSION, BENIGN, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),
ANEURYSM, OTHER
Assessment and Plan: 66F with SAH s/p coiling of AComm aneurysm
Neurologic: Neuro checks Q: 2 hr, SAH, POD 2 s/p coiling. On dilantin
100 mg po tid. Low level, received additional bolus last pm, currently
8.9. Vasospasm prophylaxis with nimodipine. Repeat head CT unchanged.
Monitor for total 7 days in ICU
Pain:controlled with dilaudid prn, Fiorocet, oxycodone.
Cardiovascular: hx of HTN, goal SBP 100-200 per neurosurg. BP control
w/ hydralazine, metoprolol and nimodipine, otherwise allow to
autoregulate
Pulmonary: stable on 2L NC, encourage IS, PT consult to get pt OOB.
Gastrointestinal / Abdomen: regular diet. on bowel regimen colace,
dulcolax, senna prn.
Nutrition: Regular diet
Renal: Monitor UOP and Daily Cr
Hematology:HCT stable, check daily
Endocrine: RISS, BG<150
Infectious Disease: low grade Temp, wbc stable 13.7, we will monitor
fever curve no antibiotics for now
Lines / Tubes / Drains: PIV
Wounds: none
Imaging: none
Fluids: KVO
Consults: Neuro surgery
Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)
ICU Care
Nutrition: regular diet
Glycemic Control: Regular insulin sliding scale
Lines:
20 Gauge - [**2175-5-8**] 12:39 PM
Prophylaxis:
DVT: Boots, SQ Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
Total time spent: 21 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
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:
58 yo man with with h/o ETOH abuse. Quit drinking on [**5-27**]. Had
some gait difficulty, slurred speech, confusion after that which
continued. Was to get MRI but it wasn't done. Went to [**Hospital3 **] for
vacation. Yesterday morning had very poor mental status - [**Hospital 3296**]
Hospital. Negative head CT. in ED BP 170/100, tach. labs sign for
plts in 90s, NH4 141. Intubated to protect airway. Got treated for
?meningitis, but no tap.
24 Hour Events:
INVASIVE VENTILATION - START [**2137-7-12**] 07:17 PM
actual start of veentilation in MICU6 was ~ 1830
Allergies:
Last dose of Antibiotics:
Vancomycin - [**2137-7-12**] 08:00 PM
Infusions:
Propofol - 30 mcg/Kg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2137-7-13**] 09:37 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.3
Tcurrent: 36.8
C (98.3
HR: 92 (69 - 95) bpm
BP: 153/80(98) {113/59(75) - 161/97(111)} mmHg
RR: 24 (10 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 74 Inch
Total In:
1,039 mL
1,249 mL
PO:
TF:
IVF:
979 mL
1,219 mL
Blood products:
Total out:
1,240 mL
625 mL
Urine:
1,240 mL
625 mL
NG:
Stool:
Drains:
Balance:
-201 mL
624 mL
Respiratory support
Ventilator mode: CMV/ASSIST
Vt (Set): 600 (600 - 600) mL
RR (Set): 12
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 25
PIP: 16 cmH2O
Plateau: 11 cmH2O
SpO2: 100%
ABG: 7.44/37/160/25/
Ve: 12.2 L/min
PaO2 / FiO2: 400
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
11.4 g/dL
53 K/uL
131 mg/dL
1.0 mg/dL
25 mEq/L
3.3 mEq/L
14 mg/dL
113 mEq/L
142 mEq/L
31.7 %
5.9 K/uL
[image002.jpg]
[**2137-7-12**] 09:15 PM
[**2137-7-13**] 04:15 AM
WBC
5.6
5.9
Hct
33.1
31.7
Plt
57
53
Cr
1.0
1.0
TropT
0.02
Glucose
154
131
Other labs: PT / PTT / INR:16.7/37.6/1.5, CK / CKMB /
Troponin-T:449/7/0.02, ALT / AST:35/56, Alk Phos / T Bili:92/2.7,
Amylase / Lipase:45/61, Differential-Neuts:58.3 %, Lymph:31.6 %,
Mono:6.2 %, Eos:3.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.7 g/dL,
LDH:180 IU/L, Ca++:9.4 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL
Assessment and Plan
Delirium/poor MS: Most likely hepatic encephalopathy. Reported has
not drank since [**5-27**], so ETOH withdrawl unlikely. Continue with
lactulose.
doubt meningitis with two weeks of altered MS and no fever. Also
consider Wernicke's - tx with thiamine.
alchoholic hepatitis: discriminate score about 29. will ask
hepatology if they feel treatment is warranted.
respiratory failure: will try to extubate once stooling and MS better.
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2137-7-13**] 12:00 AM
16 Gauge - [**2137-7-13**] 12:00 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer: PPI
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 40 minutes
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
Echo - Left ventricular cavity enlargement with extensive regional
systolic dysfunction c/w CAD (mid-LAD distribution, LVEF = 25-30). Mild
aortic regurgitation. Pulmonary artery systolic hypertension. Mild
mitral regurgitation. CT surgery, will likely get CABG Wed/[**Doctor First Name **], started
heparin gtt w/o bolus. Lipids at goal, A1C 5.4. Guiac pos stool. CXR
- ? R hilar mass, ordered CT chest. U/S -L ICA mod/severe stenosis
60-69% w/ interval progression; R no sign stenosis. Wound cons. Pend,
CK trending down, [**2116**]. Febrile o/n. BCx and UCx sent. Had episode of
hypxia/SOB, mild CP in HD, CXR unchanged, ECT STe in same leads as
STEMI. Given IV morphine, nebs, Nitro and back to HD.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Heparin Sodium - 1,200 units/hour
Other ICU medications:
Morphine Sulfate - [**2110-11-10**] 07:35 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 [**2110-11-11**] 06:09 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 38.4
C (101.1
Tcurrent: 37.8
C (100.1
HR: 76 (63 - 104) bpm
BP: 97/47(58) {56/33(40) - 143/125(128)} mmHg
RR: 22 (13 - 35) insp/min
SpO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 98.5 kg (admission): 100 kg
Height: 27 Inch
Total In:
927 mL
74 mL
PO:
660 mL
TF:
IVF:
267 mL
74 mL
Blood products:
Total out:
0 mL
0 mL
Urine:
NG:
Stool:
Drains:
Balance:
927 mL
74 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 92%
ABG: ///31/
Physical Examination
GENERAL: Somnlent but otherwise well-appering man in NAD. Oriented to
person, month and year.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with no appreciable JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds RR, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Lower left-midline scar s/p
appendectomy per pt.
EXTREMITIES: No femoral bruits. L arm AV fistula, + palpable thrill
and audible bruit. R femoral area soft without ecchymosis or hematoma,
no bruits, 2+ femoral pulses bilaterally. 1+ DP and PT pulses
SKIN: Ulceration on L anterior skin with eschar and granulation tissue.
Chronic skin changes of bilateral lower extremities c/w statis
dermatitis.
Labs / Radiology
170 K/uL
10.2 g/dL
99 mg/dL
8.0 mg/dL
31 mEq/L
4.1 mEq/L
36 mg/dL
92 mEq/L
138 mEq/L
30.4 %
9.6 K/uL
[image002.jpg]
[**2110-11-9**] 05:42 PM
[**2110-11-10**] 02:30 AM
[**2110-11-10**] 01:53 PM
[**2110-11-11**] 03:53 AM
WBC
8.3
7.6
9.6
Hct
30.1
30.3
30.4
Plt
160
205
170
Cr
9.4
9.8
8.0
TropT
12.68
16.03
17.03
19.10
Glucose
102
181
99
Other labs: PT / PTT / INR:15.7/61.9/1.4, CK / CKMB /
Troponin-T:1216/50/19.10, ALT / AST:30/151, Alk Phos / T Bili:348/0.4,
Albumin:3.9 g/dL, LDH:849 IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.5
mg/dL
Assessment and Plan
64yo M with hx of ESRD on HD, CAD, hypercholesterolemia, CVA p/w chest
pain and STEMI, v. fib X 3 at OSH, resolved with shock, transferred
from OSH for cardiac cath, now s/p LAD BMS stent with 3v disease.
.
# CORONARIES: Pt with hx of CAD, p/w STEMI and cath showing 3v
disease, s/p BMS stent to LAD. Now chest pain free. ECG showed
anterior ischemic changes. Pt received [**Last Name (LF) **], [**First Name3 (LF) 119**], aggrastat at OSH.
- discuss with CT surgery regarding plans for CABG; if going to be done
this week, will start heparin for anticoagulation in the setting of a
BMS and will hold on [**First Name3 (LF) **]. If not done this week, will restart
[**First Name3 (LF) **].
- continue aspirin
- bblocker, statin
- check lipid panel, HBA1C, fasting glucose in AM
.
# PUMP: No prior echos to compare. Does not appear in heart failure
clinically.
- TTE
.
# RHYTHM: S/P v. fib X 3 at OSH with shock X 3. Has been in NSR since
with some non-sustained VT 6-9 beats on tele overnight. V fib
secondary to ischemia and now reperfusion.
- stop amiodarone today.
- continue to monitor on tele
.
# ESRD on HD: unclear origin of disease. Pt dialyzed M, W, F and last
dialysis was friday per patient. Pt received aggrastat which is
renally cleared and is likely having lasting effects on clotting time.
Sheath pulled and no evidence of bleeding or hematoma.
- pt to have dialysis today
- continue Sevelamer, Nephrocaps, Sensipar
- check platelet agglutination study today
.
# COPD: not contributing factor at this time and pt on no medications
- continue to monitor
.
# Weight Loss: Due to poor PO intake per daughter. [**Name (NI) **] etiologies
may be malignancy (lung, colon cancer), metabolic (hyperthyroidism).
TSH normal. CXR done this morning.
- guiac stool, pt will need outpatient colonscopy
- f/u CXR for lung cancer screening
.
# Left leg ulcer: appears chronic
- wound care consult
.
# Hx of CVA:
- continue [**Last Name (LF) 119**], [**First Name3 (LF) 124**] give [**First Name3 (LF) 120**] or heparin as per above
.
# FEN: cardiac, renal diet, replete lytes as needed
.
# Prophylaxis: no SC heparin for now given bleeding risk, PPI as per
home tx, bowel regimen
.
# Access: 2 PIV on right arm, fistula left arm
.
# Code Status: FULL, confirmed with patient and daughter
.
# Contact: Daughter [**First Name4 (NamePattern1) 532**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2967**]
.
# Dispo: call out to floor today
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2110-11-10**] 08:30 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
EKG - At [**2148-12-2**] 08:50 AM
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
Ace Inhibitors
Cough;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2148-12-2**] 02:00 PM
Vancomycin - [**2148-12-2**] 04:28 PM
Piperacillin - [**2148-12-3**] 06:00 AM
Infusions:
Fentanyl - 50 mcg/hour
Midazolam (Versed) - 1 mg/hour
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2148-12-2**] 02:00 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 [**2148-12-3**] 08:09 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.6
C (99.6
Tcurrent: 37.5
C (99.5
HR: 93 (64 - 97) bpm
BP: 128/48(73) {86/37(54) - 171/57(90)} mmHg
RR: 20 (17 - 22) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 56.6 kg (admission): 56 kg
Total In:
4,082 mL
1,645 mL
PO:
TF:
IVF:
3,912 mL
1,645 mL
Blood products:
Total out:
1,307 mL
275 mL
Urine:
638 mL
275 mL
NG:
Stool:
Drains:
Balance:
2,775 mL
1,370 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST
Vt (Set): 400 (400 - 400) mL
Vt (Spontaneous): 165 (165 - 165) mL
PS : 0 cmH2O
RR (Set): 20
RR (Spontaneous): 9
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 13
PIP: 20 cmH2O
Plateau: 15 cmH2O
Compliance: 40 cmH2O/mL
SpO2: 100%
ABG: 7.34/52/127/25/1
Ve: 6.9 L/min
PaO2 / FiO2: 318
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)
Rub
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,
Tone: Not assessed
Labs / Radiology
155 K/uL
7.9 g/dL
67 mg/dL
2.9 mg/dL
25 mEq/L
4.6 mEq/L
46 mg/dL
110 mEq/L
144 mEq/L
23.0 %
10.4 K/uL
[image002.jpg]
[**2148-12-2**] 08:49 AM
[**2148-12-2**] 12:06 PM
[**2148-12-2**] 12:09 PM
[**2148-12-2**] 03:44 PM
[**2148-12-2**] 07:02 PM
[**2148-12-2**] 07:27 PM
[**2148-12-2**] 10:28 PM
[**2148-12-2**] 10:50 PM
[**2148-12-3**] 04:40 AM
[**2148-12-3**] 04:51 AM
WBC
10.4
Hct
29
25.0
27
23.0
Plt
155
Cr
3.2
3.0
2.8
2.8
2.9
TCO2
24
26
28
27
29
Glucose
146
73
159
137
67
Other labs: PT / PTT / INR:14.7/49.9/1.3, ALT / AST:164/102, Alk Phos /
T Bili:32/0.5, Amylase / Lipase:1485/68, Differential-Neuts:82.4 %,
Lymph:10.7 %, Mono:5.3 %, Eos:0.9 %, Lactic Acid:2.1 mmol/L,
Albumin:4.1 g/dL, LDH:254 IU/L, Ca++:9.2 mg/dL, Mg++:1.6 mg/dL, PO4:5.2
mg/dL
Assessment and Plan
PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)
PANCREATITIS, ACUTE
RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY
DISEASE)
HYPOTENSION (NOT SHOCK)
ICU Care
Nutrition:
Glycemic Control:
Lines:
Multi Lumen - [**2148-12-2**] 03:20 AM
Arterial Line - [**2148-12-2**] 03:20 AM
Dialysis Catheter - [**2148-12-2**] 05:32 AM
Prophylaxis:
DVT: SQ UF Heparin
Stress ulcer:
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status:
Disposition:
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint: 56 year old woman with metastatic breast cancer to
bone, lung and brain, presenting with worsening lower extremity edema,
found to be hypoxic and with new large right pleural effusion.
24 Hour Events:
THORACENTESIS - At [**2162-5-2**] 02:11 PM
Allergies:
Taxol (Intraven.) (Paclitaxel
Semi-Synthetic)
Anaphylaxis;
Last dose of Antibiotics:
Levofloxacin - [**2162-5-2**] 08:53 PM
Infusions:
Other ICU medications:
Pantoprazole (Protonix) - [**2162-5-2**] 08:28 AM
Morphine Sulfate - [**2162-5-2**] 05:52 PM
Heparin Sodium (Prophylaxis) - [**2162-5-2**] 10:28 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 [**2162-5-3**] 07:39 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.6
C (97.9
Tcurrent: 35.7
C (96.2
HR: 95 (95 - 119) bpm
BP: 115/74(84) {115/54(84) - 154/94(104)} mmHg
RR: 15 (15 - 27) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Total In:
2,605 mL
76 mL
PO:
690 mL
TF:
IVF:
855 mL
76 mL
Blood products:
560 mL
Total out:
697 mL
245 mL
Urine:
697 mL
245 mL
NG:
Stool:
Drains:
Balance:
1,908 mL
-169 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 98%
ABG: ///24/
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
120 K/uL
8.7 g/dL
115 mg/dL
0.5 mg/dL
24 mEq/L
4.1 mEq/L
17 mg/dL
106 mEq/L
139 mEq/L
26.3 %
10.3 K/uL
[image002.jpg]
[**2162-5-2**] 09:41 AM
[**2162-5-3**] 05:02 AM
WBC
9.7
10.3
Hct
31.2
26.3
Plt
118
120
Cr
0.5
0.5
Glucose
88
115
Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,
Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,
Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3
mg/dL
Fluid analysis / Other labs: Pleural Fluid
Chemistry
Protein 2.4
Glucose 105
Creat: 0.4
LD(LDH): 428
Albumin: 1.7
Pleural Fluid
WBC 225
RBC 315
Poly 7
Lymph 37
Mono 7
EOs
Meso: 2
Macro: 43
Other: 4
Imaging: CTA
1. No definite evidence of pulmonary emboli.
2. Extensive lung masses and nodules involving both lungs, which
appears to
have increased when compared to prior exam. Some of these masses appear
to
encase the distal segmental pulmonary arteries.
3. Extensive ground-glass opacity and septal thickening. This could
represent
lymphangitic spread or edema.
4. Hypodense lesions in the liver concerning for metastasis and fluid
within
the perihepatic space.
5. Sclerotic lesions in the lower thoracic vertebral bodies with
compression
deformities.
6. Large left pleural effusion and small right pleural effusion.
LENI
IMPRESSION: No evidence of DVT.
The study and the report were reviewed by the staff radiologist.
Assessment and Plan
RASH
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 76**])
56 year old woman with metastatic breast cancer to bone, lung and
brain, presenting with worsening lower extremity edema, found to be
hypoxic and with new large right pleural effusion.
#. RESPIRATORY DISTRESS: Currently on 4L O2, at baseline is 100%RA. As
the pt has mets in lung and unclear history of sarciod it is difficult
to discern whether the pt has pneumonia as well. No fever, minimal
cough and nl WBC (although pt does have bands, and normal WBC may be
elevated in the setting of recent Avastin and possible
myelosuppression). Suspect effusion is most likely secondary to
malignancy.
-- Levaquin for CAP
-- S/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
-- Supplemental oxygen.
#. LOWER EXTREMITY EDEMA: Concerning for venous obstruction.
-- Final LENI
s negative for DVT
-- Consider imaging of abd/pelvis (CT v MRI)
-- Elevation of LE
-- F/u final echo
#. BREAST CANCER: No plans for inpatient therapy
#. BRAIN METASTASIS: CT stable, no significant change in cerebellar
lesions
#. URINARY TRACT INFECTION: Levaquin for now. X3d
-- F/U Culture
FEN: Regular diet
PPX:
-DVT ppx with SQ Heparin and Pneumoboots
-Bowel regimen
-Pain management with Tylenol
ACCESS: PIV's
CODE STATUS: full
-- Plan for family meeting today
DISPOSITION: transfer to OMED
ICU Care
Nutrition:
Glycemic Control:
Lines:
20 Gauge - [**2162-5-2**] 02:48 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2120-8-28**] Discharge Date: [**2120-9-6**]
Date of Birth: [**2043-6-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamides) / Iodine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Pt presented s/p fall w/bilaterall lower ext weakness
w/parasthesias and difficulty handeling secretions.
Major Surgical or Invasive Procedure:
Cervical stabilization anterior partial vertebrectomies
c4-5,c6-7 [**2120-8-30**]
Past Medical History:
Past Medical History:
diabetes type II
mild asthma
[**Doctor Last Name 3271**]-[**Doctor Last Name **] virus
lower extremity edema
newly diagnosed T3N1 poorly differentiated esophageal cancer
PAST SURGICAL HISTORY:
Significant for inguinal hernia repair in [**2082**] and status post
exploratory laparotomy in [**2098**] for abdominal pain at which they
performed an incidental cholecystectomy and appendectomy.
Social History:
He lives in [**Location (un) 3844**] where he has lived for the past 40
years with his partner. [**Name (NI) **] works as a cashier at a bookstore. He
smoked 50-pack year quitting 15 years ago. He does not drink any
alcohol. He has no children.
Family History:
His mother died at age of 87 from gastric cancer and his father
died at age of 70 from cirrhosis. He has a sister who is 81
years old and has no cancer. His brother is 66 and healthy.
Physical Exam:
NAD, A&Ox3
Echymosis bilateral orbits
PERRLA
RRR
Course BS bilat
Abdomen soft, NT/ND
Neuro: +[**12-23**] left bicep, +[**1-20**] left tricep, [**2-20**] bilateral hand
grips, [**1-20**] right bicep and tricep, [**12-22**] DTR LUE, [**11-21**] LUE, 0/4
Bilat LE, bilat downgoing toes, sensation intact but describes
as "pins and needles sensation" on bilateral UE.
Pertinent Results:
[**2120-8-28**] 12:20AM GLUCOSE-95 UREA N-9 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-30 ANION GAP-10
[**2120-8-28**] 12:20AM WBC-3.7*# RBC-3.68* HGB-11.5* HCT-35.2*
MCV-96# MCH-31.4 MCHC-32.8 RDW-21.2*
[**2120-8-28**] 12:20AM NEUTS-64.2 LYMPHS-29.5 MONOS-5.9 EOS-0.3
BASOS-0.1
[**2120-8-28**] 12:20AM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-3+
[**2120-8-28**] 12:20AM PLT COUNT-148*
[**2120-8-28**] 12:20AM PT-13.5* PTT-26.5 INR(PT)-1.2
[**2120-8-28**] 12:20AM BLOOD WBC-3.7*# RBC-3.68* Hgb-11.5* Hct-35.2*
MCV-96# MCH-31.4 MCHC-32.8 RDW-21.2* Plt Ct-148*
[**2120-8-28**] 12:20AM BLOOD Neuts-64.2 Lymphs-29.5 Monos-5.9 Eos-0.3
Baso-0.1
[**2120-8-28**] 12:20AM BLOOD PT-13.5* PTT-26.5 INR(PT)-1.2
[**2120-8-28**] 12:20AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-138 K-4.0
Cl-102 HCO3-30 AnGap-10
Brief Hospital Course:
[**2120-8-28**]: Admited to TSICU after transfer from NEH on steroid
gtt. Made NPO for spinal intervention. Admited TSICU for
increased secretions.
[**2120-8-29**]: OR delayed secondary to increased secretions
[**2120-8-30**]: OR for Anterior fusion from C4-C7. Anterior partial
vertebrectomy of C5, C6, C7. Anterior discectomies C4-5, C5-6,
C6-7 Anterior instrumentation C4-C7. Structural allograft.
Stable postoperatively. Right groin line placed after failed
attempt on right subclavian w/small right apical pneumothorax.
Episode of hypotension w/position change requiring neosynephrine
and fluid boluses.
[**2120-8-31**]: Hematocrit drop from 33 to 26. Transfused.
[**2120-9-1**]: OR for: Total laminectomy of C3, C4, C5, C6. Fusion
C4-C7. Autograft.
Excision of soft tissue mass in the posterior cervical region.
On CPAP/PS post op w/occasional desats and increased secretions.
[**2120-9-2**]: Sputum returns w/gram neg rods w/levofloxacin
started. Attempted placement of dobhoff tube unsuccesfully.
[**2120-9-3**]: Patient extubated sucessfully.
[**2120-9-4**]: Patient failed swallow study w/frank aspiration.
Feeding tube by IR.
[**2120-9-5**]: Tube feeds started after placement of feeding tube by
IR. A-Line removed, femoral line removed w/mild hemorrhage
(approx 200cc blood loss) stopped w/direct pressure. Hct and
coags normal. Droping urine output responsive to fluid boluses.
RADIOLOGY Final Report
CT RECONSTRUCTION [**2120-8-28**] 4:02 AM
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: eval for [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with fall and head trauma, ? C-spine injury
REASON FOR THIS EXAMINATION:
eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Fall and head trauma and C-spine injury on outside
CT and MRI, evaluate fracture.
COMPARISON: None available at the time of dictation.
TECHNIQUE: Axial MDCT images were obtained through the cervical
spine without intravenous contrast. Additional coronal and
sagittal reformations are provided.
CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The
cervical spine is imaged from C1 through T3. There is a
minimally displaced fracture through the spinous process of C4
extending to the posterior arch of C4. Minimally displaced
fractures of the tips of the spinous processes of C5. Mildly
displaced fracture of the spinous process of C7.
There is malalignment of the component vertebrae at C4-5, with
grade 1 retrolisthesis of C4 on C5 and with marked widening of
the intervertebral disc space anteriorly. There is additional
widening of the intervertebral disc space anteriorly at C6-7.
There is marked narrowing of the spinal canal at C4-5 due to
retrolisthesis of C4 on C5 and angulation of the spine at this
level.
The prevertebral soft tissues are widened diffusely. In
addition, there is a suggestion of hyperdensity within the
widened intervertebral disc spaces at C4-5 and C6-7 as well as
within the prevertebral soft tissues, possibly representing
hematoma.
There is an additional questionable linear lucency within the
anterior inferior aspect of the C2 vertebra on the sagittal
views only without clear correlate on the axial views, finding
that could represent artifact Vs. a nondisplaced fracture.
The visualized portions of the lung apices appear unremarkable.
IMPRESSION:
1. Fractures of the spinous processes at C4, C5, and C7.
2. Cervical spine malalignment of C4-5 and C6-7, with
retrolisthesis and intervertebral disc space widening at C4-5
and disc space widening at C6-7, and spinal stenosis. The
findings are highly suggestive of ligamentous injury at these
locations. MRI should be considered for assessment of the spinal
cord as well as soft tissues.
3. Marked expansion of the prevertebral soft tissues consistent
with hematoma and edema.
4. Questionable artifact Vs. nondisplaced fracture of the
anterior inferior corner of C2 vertebra, seen on the sagittal
reconstructions only.
Results were discussed with the orthopedic resident at the time
of interpretation (4:45 a.m.).
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8913**] R.M. SUN
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: WED [**2120-8-28**] 8:58 AM
Medications on Admission:
Actose 30 QD, Glucophage 250 QD, Methadone
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: [**11-19**] Inhalation Q4H
(every 4 hours).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for Mg<2.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
6. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for K<4.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO ONCE (once) for 1 doses.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
13. Magnesium Sulfate 50 % Solution Sig: One (1) Injection ONCE
(once) for 1 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Cervical subluxation C4-5
Central cord syndrome
Discharge Condition:
good
Discharge Instructions:
keep collar on when out of bed. Keep incision clean and dry.
Daily dressing changes to surgical incisions.
Physical Therapy:
Activity: Bedrest with bed position
Pneumatic boots
Cervical collar: At all times
may elevate HOB
No heavy lifting (no lifting>10lbs)
Treatments Frequency:
Site: ant/post cervical
Type: Surgical
Dressing: Gauze - dry
Change dressing: qd
Site: Healing incision to ant, neck
Description: Incision
Care: dry sterile dressing
Followup Instructions:
10 days from date of discharge with Dr [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
Completed by:[**2120-9-6**]
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint: Acute respiratory failure, pneumonia
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
PICC LINE - START [**2105-12-10**] 10:15 AM
MULTI LUMEN - STOP [**2105-12-10**] 04:05 PM
Trial of diuresis yesterday
Hypotensive SBP - 60's overnight, given 250 cc IV NS and increased neo
with BP increase to 90's.
Upper airway secretions reduced with scopolamine patch
Patient unable to provide history: Sedated, intubated
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2105-12-11**] 07:55 AM
Vancomycin - [**2105-12-11**] 07:55 AM
Infusions:
Phenylephrine - 1.2 mcg/Kg/min
Midazolam (Versed) - 2 mg/hour
Fentanyl - 50 mcg/hour
Other ICU medications:
Furosemide (Lasix) - [**2105-12-10**] 12:12 PM
Famotidine (Pepcid) - [**2105-12-10**] 08:45 PM
Heparin Sodium (Prophylaxis) - [**2105-12-11**] 07:55 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Pain: No pain / appears comfortable
Flowsheet Data as of [**2105-12-11**] 10:13 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.4
C (99.3
Tcurrent: 36.8
C (98.2
HR: 69 (63 - 80) bpm
BP: 104/46(66) {76/37(51) - 160/64(96)} mmHg
RR: 18 (13 - 22) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Height: 62 Inch
Total In:
3,082 mL
1,484 mL
PO:
TF:
1,148 mL
352 mL
IVF:
1,534 mL
982 mL
Blood products:
Total out:
1,420 mL
490 mL
Urine:
1,420 mL
490 mL
NG:
Stool:
Drains:
Balance:
1,662 mL
994 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 365 (365 - 450) mL
PS : 10 cmH2O
RR (Set): 8
RR (Spontaneous): 31
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 81
PIP: 15 cmH2O
Plateau: 17 cmH2O
SpO2: 98%
ABG: 7.37/44/96.[**Numeric Identifier 7**]/23/0
Ve: 12.1 L/min
PaO2 / FiO2: 242
Physical Examination
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Breath Sounds: Rhonchorous: bilaterally )
Abdominal: Soft, Bowel sounds present
Extremities: Right: 1+, Left: 1+
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
9.7 g/dL
421 K/uL
125 mg/dL
0.6 mg/dL
23 mEq/L
3.8 mEq/L
16 mg/dL
104 mEq/L
137 mEq/L
28.0 %
25.0 K/uL
[image002.jpg]
[**2105-12-8**] 04:50 AM
[**2105-12-8**] 12:46 PM
[**2105-12-8**] 08:33 PM
[**2105-12-9**] 03:29 AM
[**2105-12-9**] 03:48 AM
[**2105-12-9**] 02:28 PM
[**2105-12-9**] 08:34 PM
[**2105-12-10**] 01:56 AM
[**2105-12-11**] 03:56 AM
[**2105-12-11**] 06:15 AM
WBC
27.6
23.3
25.0
Hct
30.3
30.0
27.6
28.0
Plt
[**Telephone/Fax (3) 2259**]
Cr
0.6
0.6
0.5
0.5
0.6
TCO2
21
23
22
26
Glucose
[**Telephone/Fax (3) 2260**]38
125
Other labs: PT / PTT / INR:16.9/41.3/1.5, CK / CKMB /
Troponin-T:228/7/0.06, D-dimer:1665 ng/mL, Lactic Acid:1.7 mmol/L,
Ca++:7.3 mg/dL, Mg++:1.7 mg/dL, PO4:2.9 mg/dL
Microbiology: C. Diff negative x 1
Assessment and Plan
ACUTE HYPOXIC RESPIRATORY FAILURE secondary to pneumonia. Secretions
are unchanged, thick tan. Concerning that WBC going back up. Having
diarrhea, sending stool for C. Diff. CXR suggests possible pleural
effusion, concerned for complicated parapneumonic effusion vs.
empyema. Will obtain CT chest today. Repeat sputum gram stain, C+S,
blood and urine cultures. Continue vanco/zosyn.
ATRIAL FIBRILLATION (AFIB): Remains in SR on amiodarone.
HYPOTENSION secondary to hypovolemia in setting of diuresis. Improved
with fluids albeit also required increased neo, now being weaned back
down.
ICU Care
Nutrition:
Comments: Tube feeds at goal.
Glycemic Control:
Lines:
Arterial Line - [**2105-12-8**] 07:00 AM
20 Gauge - [**2105-12-8**] 07:00 AM
PICC Line - [**2105-12-10**] 10:15 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP:
Need for restraints reviewed
Comments:
Communication: Comments:
Code status: Full code
Disposition :ICU
Total time spent: 55 minutes
Patient is critically ill
------ Protected Section ------
CT chest shows dense consolidation on the left, mulitlobar involvement,
areas of external compression with obstruction of bronchus vs.
endobronchial obstruction. Bronched through ETT with the pulmonary
fellow, moderate amounts of purulent secretions, suctioned for mucus
plugs. Edematous ariways thorughout with external compression.
Washings sent for gram stain, C+S. Chest CT also shows pleural
efffusion. If elevated WBC persists, will need to tap.
------ Protected Section Addendum Entered By:[**Name (NI) 2140**] [**Last Name (NamePattern1) 2141**], MD
on:[**2105-12-11**] 18:29 ------
|
Physician
|
Classify the following medical document.
|
TITLE:
Chief Complaint:
24 Hour Events:
Extubated yesterday, required racemic epi for upper airway sounds,
briefly without gag reflex following extubation. T max of 100.1. Amio
400 TID started. Tele: 3 short runs of NSVT.
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Bactrim (SMX/TMP) - [**2121-11-18**] 09:30 PM
Infusions:
Heparin Sodium - 1,350 units/hour
Amiodarone - 0.5 mg/min
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2121-11-20**] 07:44 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.8
C (100.1
Tcurrent: 37.3
C (99.2
HR: 64 (59 - 83) bpm
BP: 98/45(65) {93/45(65) - 146/98(328)} mmHg
RR: 18 (14 - 31) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 107 kg (admission): 104.5 kg
Height: 65 Inch
Total In:
1,308 mL
401 mL
PO:
270 mL
200 mL
TF:
IVF:
978 mL
201 mL
Blood products:
Total out:
3,270 mL
920 mL
Urine:
3,270 mL
920 mL
NG:
Stool:
Drains:
Balance:
-1,962 mL
-519 mL
Respiratory support
O2 Delivery Device: Nasal cannula
Ventilator mode: CPAP/PSV
Vt (Set): 550 (550 - 550) mL
Vt (Spontaneous): 473 (325 - 552) mL
PS : 5 cmH2O
RR (Set): 14
RR (Spontaneous): 23
PEEP: 5 cmH2O
FiO2: 50%
PIP: 11 cmH2O
SpO2: 96%
ABG: 7.41/32/89.[**Numeric Identifier 433**]/28/-2
Ve: 10.8 L/min
PaO2 / FiO2: 178
Physical Examination
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
202 K/uL
12.5 g/dL
120 mg/dL
0.6 mg/dL
28 mEq/L
4.2 mEq/L
7 mg/dL
102 mEq/L
139 mEq/L
35.0 %
8.1 K/uL
[image002.jpg]
[**2121-11-17**] 05:08 PM
[**2121-11-17**] 06:54 PM
[**2121-11-18**] 05:15 AM
[**2121-11-18**] 05:26 AM
[**2121-11-18**] 09:37 PM
[**2121-11-19**] 02:28 AM
[**2121-11-19**] 04:55 AM
[**2121-11-19**] 11:00 AM
[**2121-11-19**] 02:48 PM
[**2121-11-20**] 05:40 AM
WBC
11.4
9.8
8.1
Hct
37.7
38.0
35.0
Plt
249
223
202
Cr
0.7
0.7
0.6
TCO2
30
30
31
26
30
31
21
Glucose
126
111
120
Other labs: PT / PTT / INR:13.1/60.2/1.1, Lactic Acid:0.8 mmol/L,
Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.1 mg/dL
Assessment and Plan
URINARY TRACT INFECTION (UTI)
VENTRICULAR TACHYCARDIA, NON-SUSTAINED (NSVT)
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)
WITH ACUTE EXACERBATION
ICU Care
Nutrition:
Glycemic Control:
Lines:
Arterial Line - [**2121-11-17**] 05:00 PM
20 Gauge - [**2121-11-19**] 07:00 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
Admission Date: [**2135-7-30**] Discharge Date: [**2135-8-6**]
Date of Birth: [**2082-12-21**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old man
with a history of HIV, now viral counts are undetectable, and
350 CD4 count who presents with bloody diarrhea three times
over a 24 hour period. Patient has felt dizzy on the day
prior to admission and collapsed on the way to the bathroom.
Patient lost consciousness for an unknown period of time.
Patient stated that after this and after walking to his
apartment, he collapsed again. Patient visited [**Hospital1 778**] office
where he regularly gets his medical care. He was seen in the
afternoon and told he was dehydrated and sent home. That
same night, when the patient was at home and was on the way
to the bathroom, he had collapsed again. Patient has had
black tarry diarrhea and some episodes of bright red blood
per rectum in medium to large amounts. Patient denied having
fevers or chills. There was no change in his urine color.
There was no nausea, vomiting or abdominal pain. Patient did
not ingest any unusual food and has no recent history of
travel. Patient denied taking over the counter medications
including aspirin, Motrin and others. Patient's colonoscopy
nine months ago was negative. Patient had colonoscopy as a
screening test due to his family history of colon cancer.
PAST MEDICAL HISTORY: CMV retinitis, PCP, [**Name10 (NameIs) 10619**] sarcoma,
all HIV related, neuropathy, depression and hypertension.
SOCIAL HISTORY: No tobacco, alcohol or drug use.
MEDICATIONS ON ADMISSION: Zestril, Lipitor, Wellbutrin,
amitriptyline and HIV medications were: Zerit 20 mg po
b.i.d., lamivudine 150 mg po b.i.d. and Sustiva 600 mg po
q.h.s.
ALLERGIES: To sulfa. Patient becomes anaphylactic.
PHYSICAL EXAMINATION: Revealed a 52-year-old man in no acute
distress, appearing comfortable, sitting in a hospital bed.
Vital signs on admission were 97. Heart rate 82.
Respiratory rate 19. Blood pressure 104/54 and 100% on room
air. Head, eyes, ears, nose and throat exam revealed no
lymphadenopathy, no jugular venous distention. Oropharynx
was clear with no blood in the oral cavity. Dentition was
normal. Lungs were clear to auscultation bilaterally. No
crackles. Heart: Regular rate and rhythm, no murmurs, rubs
or gallops, S1, S2 normal. Abdomen: Soft, nontender,
nondistended, positive bowel sounds, it was grossly guaiac
positive. There was blood evident on the rectal exam.
Extremities were within normal limits. There was no
cyanosis, clubbing or edema. There was no costovertebral
angle tenderness. Skin revealed no rashes and neurological
exam was nonfocal. Strength was [**5-7**] in upper and lower
extremities and sensation was grossly intact.
LABS ON ADMISSION: White blood cells were 12.4, hematocrit
22.6, platelets 212,000. Sodium 138, potassium 4.8, chloride
102, bicarbonate 22, BUN 40, creatinine 1.0, glucose 126.
His urinalysis was negative. His electrocardiogram showed
diffuse T wave flattening in I, III and aVF leads, as well as
biphasic T waves in V4 through V6. There was no findings
suggestive of acute ischemia.
HOSPITAL COURSE: During the course of his hospitalization,
Mr. [**Known lastname 10620**] has had some active bleeding and has required
a transfusion of a total of 11 units of packed red blood
cells over the course of his hospitalization. He has
undergone extensive work-up which has been unrevealing. His
tests included: Esophagogastroduodenoscopy, colonoscopy,
enteroscopy, small bowel follow through and tagged red blood
cells scan. All of these tests, again, were negative. The
patient was maintained on intravenous Protonix and was
aggressively resuscitated with fluids in addition to packed
red blood cells as mentioned. The patient was also
transferred to the Medical Intensive Care Unit for a period
of two days during his hospitalization. Over the course of
the last 72 hours, patient's hematocrit has remained stable.
Therefore, patient will be discharged home today. He will
live with his friend for two weeks. Therefore, patient will
be monitored if he has any recurrent episodes of collapse.
No follow-up with Gastroenterologist has been recommended by
the Gastrointestinal Service. The patient, however, will
follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9625**]. Per
Gastrointestinal Service, if the patient rebleeds, immediate
CT angiogram would be recommended.
HIV. During the hospital course patient was continued on his
regular outpatient HIV management.
Depression: Patient also continued on his outpatient
management consisting of Wellbutrin and amitriptyline.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10621**], M.D. [**MD Number(1) 10622**]
Dictated By:[**Last Name (NamePattern4) 10623**]
MEDQUIST36
D: [**2135-8-9**] 20:02
T: [**2135-8-9**] 20:02
JOB#: [**Job Number 10624**]
|
Discharge summary
|
Classify the following medical document.
|
Admission Date: [**2120-8-16**] Discharge Date: [**2120-8-20**]
Date of Birth: [**2067-7-3**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Clarithromycin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2120-8-16**] with DES to LAD.
History of Present Illness:
The patient is a 53 yo man with h/o HTN and gout, who presented
with acute onset chest pain. The patient states that he was in
his normal state of health until approximately 8 PM last night,
when he developed acute onset chest pain in the setting of
moving a mattress. The patient states that the pain was [**9-16**],
"pressure," located substernally and radiating to his left
shoulder and back. He had associated diaphoresis. His wife,
who was a RN in [**Country 532**], convinced him to come to the ED, where
he presented at approximately 1:30 am.
In the ED, the patient's VS were T 97.9, BP 126/87, P 82, R 20,
O2 97% on RA. A Code STEMI was called, and the patient was
taken emergently to the cath lab at 3 am. He was given ASA 325
mg, O2, NTG SL, Plavix 600 mg, Morphine, and he was started on a
heparin gtt.
In the cath lab, the patient was found to have a 100% occlusion
of the proximal LAD. A thrombectomy was performed, and a DES
was placed in the LAD. He was then admitted to the CCU for
further observation.
On arrival to the floor, the patient states that he is no longer
experiencing chest pain. He has stomach pain which began
shortly after the procedure, but he states that this is markedly
different from the pain which brought him into the hospital.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
GERD
IBS
PUD with negative H.pylori
h/o NASH
B12 deficiency
Vitamin D deficiency
Nephrolithiasis
Gout
Seasonal allergies
s/p cholecystectomy in [**2113**]
Social History:
The patient is married and lives with his wife. [**Name (NI) **] currently
drives a taxi for a living and has one son who lives in the
[**Name (NI) 86**] area. Son is alive and well, w/ active lifestyle.
-Tobacco history: The patient previously smoked for 30 years and
quit in [**2106**]
-ETOH: Only on holidays
-Illicit drugs: None.
Family History:
The patient's mother passed away from pancreatic cancer. His
father died when the patient was 10 in [**Country 532**]. No known family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 98.8, BP 114/70, HR 91, RR 18, O2 sat 94% on 4L
GENERAL: Middle aged man, pleasant, anxious and emotional, in
NAD. Oriented x 3
HEENT: PERRL, EOMI, Oropharynx clear and without exudate.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Femoral catheter site
c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2120-8-16**] 02:30AM
WBC-14.2 Hct-45.1 Plt Ct-217
Neuts-80.9* Lymphs-15.6* Monos-2.9 Eos-0.2 Baso-0.4
COAGs: PT-14.3* PTT-99.4* INR(PT)-1.2*
144 | 105 | 18 /114
4.1 | 20 | 1.4 \
Calcium-9.3 Phos-4.5 Mg-1.8
LFT's: ALT-72* AST-91* LD(LDH)-352* CK(CPK)-755* AlkPhos-93
TotBili-0.5
Cardiac Enzymes
[**2120-8-16**] 02:30AM CK 755 CKMB 32 MBindex 4.2 cTropnT-0.31*
[**2120-8-16**] 10:00AM CK-MB-189* MB INDX-2.9 cTropnT-13.33*
CK(CPK)-6439*
[**2120-8-16**] 03:05PM CK-MB-107* MB INDX-2.2 cTropnT-8.67*
CK(CPK)-4791*
[**2120-8-16**] 07:00PM CK-MB-74* MB INDX-1.8 CK(CPK)-4013*
[**2120-8-16**] 12:05PM BLOOD Type-ART pO2-66* pCO2-31* pH-7.50*
[**2120-8-16**] 12:05PM BLOOD Lactate-1.8
PERTINENT LABS/STUDIES:
EKG ([**8-16**]): NSR at 77 bpm. Q waves in V1-V5. 3mm ST elevation
in V2-V4. No R wave progression in precordial leads.
ETT ([**2115-5-8**]): The patient exercised for 6.5 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol and was stopped for fatigue. Fair functional capacity.
The patient was asymptomatic throughout. The rhythm was sinus
with no ectopy. No significant ST segment changes. Appropriate
hemodynamic response to imposed demands. IMPRESSION: No
objective evidence of myocardial ischemia by EKG or anginal
symptoms at the achieved level of work. 1) Normal myocardial
perfusion. 2) Normal left ventricular cavity size and systolic
function
CARDIAC CATH:
- LAD: 100% occlusion with thrombus, now s/p thrombectomy and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placement
- LCx: 30% diffuse mid
- RCA: 30% mid
HEMODYNAMICS:
RA 11 (mean), RV: 49/11, PCWP: 25, PA: 42/23,
LABORATORY DATA:
Troponin: 0.31
CK 755, MB 32, MBI 4.2
BMP: Na 144, K 4.1, Cl 105, HCO3 20, BUN 18, Cr 1.4 (baseline
1.2-1.3), Glucose 109
CBC: WBC 14.2, Hct 45.1, Plt 217
PT 14.3, PTT 99.4, INR 1.2
Cholesterol Panel ([**5-16**]): Total cholesterol 191, Triglycerides
235, HDL 37, LDL 107
ECHO [**2120-8-16**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe regional left ventricular systolic
dysfunction with akinesis of the anterior wall, septum and the
apex. The remaining segments exhibit compensatory hypERkinesis
(LVEF = 30%). There is spontaneous echo contrast at the LV apex,
but no formed thrombus at this time. Moderate to severe left
ventricular systolic dysfunction, c/w proximal LAD infarction.
No significant valvular disease. Mild pulmonary hypertension.
Findings discussed with Dr. [**Last Name (STitle) **] at 11a on the day of the
study.
DISCHARGE LABS:
[**2120-8-20**] 05:40AM BLOOD WBC-10.0 RBC-4.12* Hgb-13.0* Hct-37.4*
MCV-91 MCH-31.5 MCHC-34.6 RDW-14.4 Plt Ct-242
[**2120-8-20**] 05:40AM BLOOD PT-14.9* PTT-30.3 INR(PT)-1.3*
[**2120-8-20**] 05:40AM BLOOD Glucose-94 UreaN-22* Creat-1.4* Na-142
K-4.5 Cl-106 HCO3-23 AnGap-18
Brief Hospital Course:
# STEMI: The patient was found to have ST elevations in V2-V4,
and elevated cardiac biomarkers on admission (Troponin: 0.31 CK
755, MB 32, MBI 4.2). Code STEMI was called and patient was
taken to the cath lab. There patient was found to have a 100%
occlusion and thrombus of the proximal LAD, underwent
thrombectomy and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. EKG showed improvement of ST
elevations, and chest pain resolved. The patient was started on
ASA 325 mg daily, Plavix 75 mg daily. Integrilin gtt was
continued for total duration of 18 hours. Metoprolol was started
and uptitrated gradually to 50 mg TID as tolerated. Captopril
was initially started, but was held when creatinine became
elevated in the setting of IV contrast for CT (see below). It
was restarted when creatinine returned to baseline on [**2120-8-18**].
Of note, patient has a history of erectile dysfunction on ACEi.
Home Diovan was held.
The patient had a previous history of fatty liver on Tricor.
Baseline LFTs were normal and it was decided that statin would
be started and LFT's monitored carefully. Home Prilosec was
changed to Ranitidine [**Hospital1 **] in the setting of starting Plavix.
TTE done in the morning following cath showed moderate to severe
left ventricular systolic dysfunction, c/w proximal LAD
infarction. No significant valvular disease. Mild pulmonary
hypertension. There was spontaneous echo contrast at the LV
apex, but no formed thrombus at this time.
That morning ([**2120-8-16**]), patient c/o headache, epigastric pain,
appeared diaphoretic. Repeat EKGs showed no significant change
from post-cath EKG. Patient received Tylenol, morphine and pain
improved. Given apical akinesis and pooling of blood seen on
TTE, there was concern for embolization to intestinal
vasculature.
CTA of the abdomen showed no SMA/[**Female First Name (un) 899**] thrombus or GI bleed.
Patient received Mucomyst and hydration prior to CTA.
In the setting of poor LV dysfunction/apical stasis and high
risk for thrombus/emboli, patient was started on heparin gtt,
with goal 60-80. Coumadin was started [**2120-8-17**]. Patient had no
further chest or epigastric pain during hospital course. Cardiac
biomarkers trended down, and patient remained hemodynamicaly
stable. He was discharged on Metoprolol, Aspirin, Plavix,
Atorvastatin and Lisinopril. For his anticoagulation, he was
discharged on Lovenox SC injection and Warfarin with plan to
have INR checked 3 days post-discharge and discontinue Lovenox
as able.
# Congestive Heart Failure: Acute systolic and diastolic CHF.
The patient had elevated RVEDP on cardiac catheterization (24).
TTE (see above) showed LVEF 30% with apical akinesis. The
patient received Lasix prn.
#. Hyperlipidemia: The patient has a history of hyperlipidemia,
though he reportedly developed NASH in the setting of TriCor. He
was started on 80 mg atorvastatin during admission since he is
now post-STEMI. Baseline LFTs were normal, and LFT's should be
monitored carefully as an outpatient.
# Acute Kidney Injury: Patient's creatinine bumped from baseline
1.2 to 1.7 after receiving contrast both in the cath lab and for
CTA, despite pre-treatment with mucomyst and IVF. Medications
were renally dosed and ACEi was held. Creatinine trended down to
baseline and captopril restarted on [**2120-8-18**].
#. Gout: Patient had no evidence of acute gout flare-up, he was
continued home Allopurinol, but the dose was decreased to 150 mg
daily given creatinine clearance.
#. GERD: The patient was taking Omeprazole for his GERD at
home. This was changed to Ranitidine in the setting of Plavix
use.
Medications on Admission:
Amlodipine 5 mg daily
Hydrochlorothiazide 25 mg daily - Stopped
Atenolol 50 mg daily - Stopped
Diovan 160 mg daily - Stopped
Allopurinol 300 mg daily
Prilosec 40 mg daily
Clobetasol 0.05% ointment [**Hospital1 **]
Vitamin B12 1000 mcg injections monthly
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for one year.
Disp:*30 Tablet(s)* Refills:*11*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please check PT/INR on Thursday [**2120-8-20**] and call results to Dr.
[**Last Name (STitle) **].
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day: Take until INR > 2.0.
Disp:*6 syringes* Refills:*2*
9. Warfarin 2 mg Tablet Sig: 3.5 Tablets PO once a day.
Disp:*105 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction with Apical Akinesis
Hyperlipidemia
Hypertension
Acute Systolic Congestive Heart Failure
Discharge Condition:
Improved. Vital signs have been stable, patient ambulating
without issues.
Discharge Instructions:
-You were admitted with sudden onset chest pain and diagnosed as
having a heart attack. You were taken to the cardiac
catheterization lab where a blood vessel supplying the heart was
found to be blocked. The blockage was cleared and a stent placed
in the vessel to keep it open. Since coming to the Cardiac unit,
you have been started and continued on medications to maximize
your heart function and recovery.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> START Warfarin 7 mg daily for prevention of blood clots.
You will need regular INR checks at the coumadin clinic at [**Company 191**].
--> START Lovenox injections twice daily in place of the heparin
drip to prevent blood clots. Stop taking Lovenox when your INR
is greater than 2.0.
--> START full-strength aspirin 325 mg daily to keep the stent
open
--> START Plavix 75mg daily. It is important that you continue
this medication (at least for a year) as it keeps the new stent
in your heart clear. Do not stop taking Plavix unless Dr. [**Last Name (STitle) **]
tells you to.
--> START Atorvastatin 80mg daily for your cholesterol
--> START Toprol XL 150mg daily for your blood pressure.
--> START Lasix (Furosemide) 10 mg daily to prevent fluid
buildup
-->STOP your atenolol 50mg daily.
-->STOP your Amlodipine 5mg daily.
--> START Ranitidine 150mg twice a day for your GERD/reflux. It
is important that you do not resume your Prilosec (omeprazole);
Prilosec and other proton pump inhibitors have been found to
decrease the effectiveness of Plavix on keeping stents clear
--> CONTINUE your Allopurinol 300mg daily, Clobetasol Propionate
0.05% Ointment twice daily, Vitamin B12 injections.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools. You should weigh yourself every
morning and call your PCP if your weight increases by more than
3 lbs within one day on 6 pounds within 3 days. Also try to
adhere to a low salt (2 gram), low fat diet.
Followup Instructions:
Primary Care:
[**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-8-22**] 2:30
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Phone: [**Telephone/Fax (1) 62**]. Date/time: [**10-8**] at
2:40pm.
Dermatology:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2120-9-13**]
11:15
Rheumatology:
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2120-9-18**]
2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
Discharge summary
|
Classify the following medical document.
|
Chief Complaint:
24 Hour Events:
BLOOD CULTURED - At [**2119-6-27**] 12:26 AM
FEVER - 102.8
F - [**2119-6-27**] 12:24 AM
- Conjugated hyperbilirubinemia
- Vitamin K 5mg PO x1
- ID - Continue antibiotics, continue surveillance cultures. Persistent
fevers not concerning at this point. If continues, consider CT chest to
reassess for abscess.
- Pulmonary - Cautious fluid resuscitation, no plan for bronchoscopy
- [**Doctor First Name **], ANCA pending
- 2:00PM - LFTs, hyperbilirubinemia, platelet count, coagulopathy,
fibrinogen, FDP stable
- Levophed stopped at 2:30pm, restarted at 6:00pm
- 6pm: 7.36/34/83, Lactate 1.3
- No new culture data (as of 10:30pm)
- 12am: Spiked to 102.8 (rectal); hypertensive, and Levophed was
weaned; blood cultures sent; blood pressure slowly came down, MAPs
remained over 55
Allergies:
Morphine
Unknown;
Amlodipine
Unknown;
Last dose of Antibiotics:
Piperacillin/Tazobactam (Zosyn) - [**2119-6-24**] 02:00 PM
Levofloxacin - [**2119-6-26**] 04:21 PM
Nafcillin - [**2119-6-27**] 04:00 AM
Infusions:
Fentanyl - 100 mcg/hour
Midazolam (Versed) - 4 mg/hour
Norepinephrine - 0.06 mcg/Kg/min
Other ICU medications:
Famotidine (Pepcid) - [**2119-6-26**] 08:00 AM
Heparin Sodium (Prophylaxis) - [**2119-6-27**] 12:00 AM
Other medications:
Changes to medical and family history:
None
Review of systems is unchanged from admission except as noted below
Review of systems:
Intubated, sedated
Flowsheet Data as of [**2119-6-27**] 06:34 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 39.3
C (102.8
Tcurrent: 38.2
C (100.8
HR: 86 (71 - 105) bpm
BP: 109/51(70) {82/44(55) - 134/63(84)} mmHg
RR: 22 (16 - 24) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Height: 72 Inch
CVP: 11 (9 - 13)mmHg
Total In:
4,733 mL
777 mL
PO:
TF:
350 mL
223 mL
IVF:
3,914 mL
425 mL
Blood products:
Total out:
1,310 mL
260 mL
Urine:
1,310 mL
260 mL
NG:
Stool:
Drains:
Balance:
3,423 mL
517 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST
Vt (Set): 500 (500 - 500) mL
RR (Set): 20
RR (Spontaneous): 5
PEEP: 8 cmH2O
FiO2: 50%
RSBI: 58
PIP: 16 cmH2O
Plateau: 17 cmH2O
Compliance: 55.6 cmH2O/mL
SpO2: 96%
ABG: 7.36/36/116/18/-4
Ve: 10.9 L/min
PaO2 / FiO2: 232
Physical Examination
Labs / Radiology
294 K/uL
10.5 g/dL
119 mg/dL
2.5 mg/dL
18 mEq/L
3.6 mEq/L
40 mg/dL
110 mEq/L
139 mEq/L
32.3 %
9.8 K/uL
[image002.jpg]
[**2119-6-25**] 04:51 AM
[**2119-6-25**] 03:52 PM
[**2119-6-25**] 06:39 PM
[**2119-6-25**] 08:48 PM
[**2119-6-26**] 04:24 AM
[**2119-6-26**] 05:32 AM
[**2119-6-26**] 02:37 PM
[**2119-6-26**] 06:05 PM
[**2119-6-27**] 05:25 AM
[**2119-6-27**] 05:39 AM
WBC
10.2
9.8
Hct
33.1
35.0
32.3
Plt
[**Telephone/Fax (3) 6197**]
Cr
2.0
2.1
2.5
TCO2
25
19
19
20
20
21
Glucose
106
112
119
Other labs: PT / PTT / INR:24.7/36.0/2.4, CK / CKMB /
Troponin-T:339/6/0.51, ALT / AST:59/106, Alk Phos / T Bili:59/4.7,
Differential-Neuts:70.0 %, Band:1.0 %, Lymph:14.0 %, Mono:13.0 %,
Eos:0.0 %, Fibrinogen:620 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.6
g/dL, LDH:366 IU/L, Ca++:6.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL
Assessment and Plan
82M with hypertension, essential tremor admitted with NSTEMI, now with
MSSA pneumonia complicated by sepsis, enlarging right sided infiltrate
1. Hypoxic respiratory failure: Tolerated pressure support briefly
yesterday. Now currently on assist control. Large A-a gradient by blood
gas. Patient with component of respiratory alkalosis, although this may
be compensatory given metabolic acidosis.
- Pneumonia treatment as below
- Vent parameters per ARDSnet protocol
- Pulmonary recs
2. Pneumonia/sepsis: MSSA pneumonia. Patient with persistent fevers,
although lower grade. ID involved.
- Discuss with ID
given persistent fevers, should we expand
coverage for anaerobes?
- Continue Nafcillin for total 3 week course through [**2119-7-11**]
(start date [**6-21**], Vancomycin initiation date) and levofloxacin for
total 8 day course ([**2119-6-24**] through [**2119-7-2**])
- Follow culture data
- Maintain CVP 8-12, MAP>60; if falls below this, bolus IVF
(LR given non-anion gap metabolic acidosis potentially secondary to
NS); wean Levophed as tolerated
- CIS
3. Coagulopathy: INR elevated to 2.4, confirmed on recheck.
Differential includes DIC (FDP 10-40, although elevated fibrinogen and
PTT normal), shock liver (LFTs improved since admission). Could also be
nutritional deficiency.
- Vitamin K PO x1
- Recheck coags, FDP, fibrinogen this afternoon
4. s/p NSTEMI: Cath showed clean coronaries, NSTEMI possibly caused by
thrombus that had since resolved with medical therapy. Likely demand
ischemia in the setting of pneumonia.
- Continue ASA
- Hold beta-blocker in the setting of sepsis
- Hold Plavix at this time given concern for PAH (very low
likelihood)
- Continue statin
5. PUMP: TTE with newly depressed EF 35-40% with inferolateral and
apical hypokinesis
- Beta-blocker on hold as above
- Would benefit from ACE inhibitor once over acute illness
- Hold Plavix and heparin given mention of potential PAH,
although this is unlikely; will likely restart heparin in next 1-2 days
given concern for thrombus formation at site of hypokinesis
6. ACUTE RENAL FAILURE: Baseline 1.0. Creatinine slowly trending up,
likely prerenal given sepsis.
- Renally dose meds
ICU Care
Nutrition:
Nutren Pulmonary (Full) - [**2119-6-27**] 12:00 AM 40 mL/hour
Glycemic Control:
Lines:
20 Gauge - [**2119-6-24**] 10:14 PM
Arterial Line - [**2119-6-24**] 11:29 PM
Multi Lumen - [**2119-6-25**] 02:49 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition:
|
Physician
|
Classify the following medical document.
|
55 y.o. male with PMHx of DM, HTN, CAD s/p IMI with 3 stents to RCA and
recently diagnosed RCC who was transferred from [**Hospital3 **]for
ongoing work-up of acute renal failure and change in mental status.
.
Patient was admitted to [**Hospital3 **]Hospital on [**2165-4-16**] for chest
and abdominal pain. He ruled out for an MI with cardiac biomarkers and
was felt to be constipated (on CT) due to chronic narcotic use for
lower back pain and right hip pain (awaiting hip replacement). His
constipation was treated aggressively with medications and disimpaction
with minimal effect. On day 4 of his hospitalization, he was febrile to
104 with a leukocytosis to 14 and was pan-cultured while Vancomycin and
Zosyn were started empirically with specific concern for a PIV
infection suggested by surrounding erythema and edema. Blood cultures
later grew GPCs in [**2-23**] bottles and chronic foot ulcers were swabbed and
reportedly grew staph aureus with pending sensitivities. Zosyn was thus
discontinued. In the setting of infection, patient became delirious,
noted to be attempting to grab things from the air and talking to
people in the room. Of note, patient was continued on narcotics,
reportedly at the wife's insistence given concern for narcotic
withdrawal. Neurology was consulted and recommended a head CT which was
unremarkable, leaving them to conclude that the mental status was
toxic/metabolic in the setting of infection and narcotic use. He was
started on Ceftriaxone 2 grams daily for CNS coverage though no LP was
performed. On day 5, patient was noted to develop acute renal failure
with a creatinine of 3, up from 1.3 and was also anuric. CKs were
checked to evaluate renal failure from rhabdomyolysis and were not
likely contributing at a level of 361. He was transferred [**4-21**] to [**Hospital1 1**]
for concern of his renal failure progressing to the point of needing
HD, since [**Hospital3 6341**] no HD facilities.
.
Upon arrival, patient was noted to vomit and had reportedly vomited en
route to [**Hospital1 1**]. He additionally started experiencing low-amplitude,
rhythmic clonus of his hands and legs, became transiently hypoxic and
was not verbally responsive. There was concern for seizing and patient
was urgently intubated to protect his airway. Discussion with the
patient's wife, [**Name8 (MD) **] RN, revealed that the patient has never had a
seizure disorder and does not drink alcohol. Additionally, he had a CT
scan with contrast at [**Hospital1 49**] 3 days prior to his admission to [**Hospital 6342**]as a part of his RCC work-up and the wife expressed concern for
contrast-induced nephropathy. Patient was then ordered for a stat head
CT given the mental status and neurology was consulted for further
assistance with management. LP [**4-23**] + for meningitis, TEE neg for
vegetation.
Meningitis, bacterial
Assessment:
Pt O X 1, following commands with encouragement. Speech normal, but
saying random words. MAE, PEARL @ 3mm/brisk bilat. [**Month/Day (2) 6643**] restless.
Pt had rec
d Haldol 2mg IM overnight for yelling/verbal abuse with good
results. VSS with HR 71-87SR with occas PVC
s, BP 152/51-165/56.
Low-grade temp persists, presently 99.6ax. Lung snds clear, diminished
in bases with non-productive cough. O2 sat 93-96% on 4l NC with RR
21-26 and regular.
Action:
Soft wrist restraints remain in place bilat for pt safety. Pt freq
reoriented. Pt rec
d Vancomycin with HD.
Response:
MS [**Month/Day (2) **] to slowly improve.
Plan:
[**Month/Day (2) **] freq orientation, monitoring for change in MS. [**First Name (Titles) **] [**Last Name (Titles) 6636**] tx.
Follow-up cx results.
Renal failure, acute (Acute renal failure, ARF)
Assessment:
AM BUN/creat 54/5.8. Pt had rec
d Lasix 120mg X 1 yesterday with 1
liter diuresis resulting. Urine yellow/clear, draining @ 20-45ml/hr.
LOS fluid balance +4.8liters.
Action:
Pt rec
d HD today, removing 3liters over 4hrs.
Response:
HD tolerated well, no change in BP.
Plan:
[**Last Name (Titles) **] to monitor fluid balance, BUN/creat.
Impaired Skin Integrity
Assessment:
Pt has 3 dry ulcers on L foot. Two ulcers on bottom of foot
(2cmX2cmX3cm deep, and 1cmX1cm), and there is a small ulcer on top of
foot (3cmX1cm). Pt had amputated toes and the foot is very dry.
Podiatry dresses ulcers with WTD dsgs daily. Also, coccyx is red, yeast
infection around coccyx/periarea.
Action:
Pt repositioned Q2hrs. Miconazole powder to yeasty areas. Foot dsg
changed/reinforced as it comes off with pt
s restlessness.
Response:
No change.
Plan:
[**Last Name (Titles) **] present WTD dsg, podiatry to follow.
Hyperglycemia
Assessment:
FSG 218, 255.
Action:
Pt [**Last Name (Titles) **] to receive TF @ goal via NGT with no residuals. Abd soft/obese
with + BS. Flexiseal draining mod amts brown loose stool. Pt rec
Insulin per sliding scale and fixed dose.
Response:
FSG @ 1600 247. Pt rec
d 8units Humalog per sliding scale.
Plan:
Tighten sliding scale, as FSG consistently in 200
s. [**Last Name (Titles) **] Q4hr
fingersticks to check glucose.
Pain control (acute pain, chronic pain)
Assessment:
Pt denied pain in am but is poor historian at the moment. [**Name2 (NI) 6643**]
groaning, trying to reposition self in bed. Pt with PMH R hip pain. At
one point yelling for
Dr [**First Name (STitle) 1071**]
, saying he needed
$50 worth of MS
Contin
Action:
Pt with Lidocaine patch on R hip, 37.5mcg patch Fentanyl. He also rec
PRN Fentnayl 50mcg IVP @ 1500.
Response:
Pt states pain ins
@ 1600.
Plan:
[**First Name (STitle) **] to freq reposition pt. Pain meds per above, with PRN Fentanyl IVP.
|
Nursing
|
Classify the following medical document.
|
[**2156-2-6**] 5:37 PM
IVC GRAM/FILTER Clip # [**0-0-**]
Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP
Contrast: OPTIRAY Amt: 40
********************************* CPT Codes ********************************
* [**Numeric Identifier 1623**] INTERUP IVC [**Numeric Identifier 1624**] INTRO CATH SVC/IVC *
* -51 MULTI-PROCEDURE SAME DAY [**Numeric Identifier 1625**] PERC PLCMT IVC FILTER *
* [**Numeric Identifier 3895**] IVC GRAM C1769 GUID WIRES INCL INF *
* C1880 VENA CAVA FILTER *
****************************************************************************
______________________________________________________________________________
[**Hospital 4**] MEDICAL CONDITION:
67 year old man with
REASON FOR THIS EXAMINATION:
High clinical suspicion PEpersitent hypoxia of sudden onsetPt cannot be
anticoagulated secondary to head bleedWOuld require filter in PE present
______________________________________________________________________________
FINAL REPORT
HISTORY: 67 y/o man with intracranial injury and hypoxia.
RADIOLOGISTS: The procedure was performed by Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) 134**] [**Last Name (NamePattern1) 135**],
with the attending radiologist Dr. [**First Name (STitle) 135**] being present during the entire
procedure.
PROCEDURE AND FINDINGS: The risks and benefits were explained to the
patient's family and consent was obtained.
The patient was placed supine on the angiographic table and the right groin
was prepped and draped in sterile fashion. Under local anesthesia using 1%
Lidocaine, the right common femoral vein was accessed with a 19 gauge needle
and 0.035 [**Last Name (un) 414**] wire was advanced into the inferior vena cava. The needle
was exchanged for a 4 FR Omniflush catheter with its tip just above the IVC
bifurcation. Inferior vena cavogram was performed with injection of nonionic
contrast diluted to half which demonstrated patent bilateral common iliac
veins and IVC with no filling defect or anomalies visualized. Both renal vein
openings were identified bilaterally. The catheter was removed and the venous
entry site was dilated over a .035 wire with increasing sized dilators
sequentially. A 15 FR long sheath was advanced over the wire into the upper
inferior vena cava. Then, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16915**] filter was deployed with tip at the
level of bilateral renal vein openings. The final X-ray demonstrated the
filter is in proper position. The sheath was removed and local hemostasis was
achieved by manual compression.
The patient tolerated the procedure well with no complications.
IMPRESSION: Successful placement of a infrarenal [**Location (un) 16915**] IVC filter.
Patent inferior vena cava. Reflux into the left common iliac vein compatible
with increased right atrial pressure.
(Over)
[**2156-2-6**] 5:37 PM
IVC GRAM/FILTER Clip # [**0-0-**]
Reason: High clinical suspicion PEpersitent hypoxia of sudden onsetP
Contrast: OPTIRAY Amt: 40
______________________________________________________________________________
FINAL REPORT
(Cont)
|
Radiology
|
Classify the following medical document.
|
65 yo M without medical history presenting for evaluation of shortness
of breath, nausea and vomiting. 5-6 days prior to admission he
developed paroxysmal cough. He obtained Tessalon Perles and an
antibiotic from a local allergist. Over the weekend, he developed
prominent GI symptoms w/ persistent nausea, forced dry heaves/wretching
and some vomiting. He noted shortness of breath and came to the ED for
evaluation on [**7-21**]. CXR demonstrated RUL PNA w/ LLL nodular density
and he was dc
d on Levofloxacin, Albuterol and Prednisone. He went home
but his GI symptoms progressed and returned to the ED.
Hospital course complicated by H1N1 diagnosis, ARDS- placed on
Rotoprone bed on [**7-24**]- tolerating 3.15hrs of being prone and 45 min
being supine. CRRT started [**7-24**]. Transitioned to HD. Pt had been in
Afib- cardioverted on [**7-24**] back to NSR. Now aflutter/ST-NSR. + C-Diff
colitis tx vanco via NGT
[**8-1**] noted diffuse drug rash which does not appear any worse.
Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, [**Doctor Last Name 11**])
Influenza A+ HINI
Assessment:
Received pt off both fent/versed gtts. Had been dc
d right before
shift change at 1830. Pt had been started on methadone [**8-1**] to help
transition off fent/vers. Did require bolus dose of each x 1 overnight
for tachypnea up to 40
s and apparent resp distress with increased
WOB. Bolus effective. At other times, pt becomes tachypneic, high
minute volumes and high pressures but then settles back out on own
without intervention. Vent mode PSV 7/5 60% RR 18-38 TV >400. Sats
90-96% transient episodes Desats with turning; however, does do well
with max rotation on triadyne. Lungs dimished throughout, slight
rhonchi to bases. None to scant tan secretion. HR 85-110
s, NSR-ST
with pac
s and pvc
s. MAPS>60. Responsive to verbal and painful
stimulation as evidenced by opening eyes. Noted to have movement in
upper ext
s-not purposeful at this time. Moves left arm > right. Does
not follow any commands. No movement from LE
s. Grimaces with pain
and opens eyes. Illiciting strong cough. Opens eyes spont with
vigorous stimulation not tracking surroundings pupils 2mm equal react
brisk. T max 102.5. WBC 8.9 (up from 7.6) , +diffuse drug rash.
S/p HD on [**8-2**] with 3.2 L off (did transiently drop bp during HD and
required getting a little fluid back but still total of 3.2 off) Peep
weaned from 12 to 7 yesterday. Sats 90-95%.
Action:
methadone dose cut in half as ordered by MD. Seraquel dose PRN if
needed. Peep weaned from 12 to 8 on days and weaned from 8 to 7 this
shift. VBG done as pt without aline. Tylenol given. PO abx as
ordered.
Response:
Maintaining sats with peep wean with exception of turn/stimulation in
which case placed on 100% o2 suction. Cont to spike temps. No culture
growth to date.
Plan:
Wean Peep as tol
Cont sedation with methadone.
Plan fent/versed bolus PRN
Cont PO vanco x 14 days.
Renal failure, acute (Acute renal failure, ARF)
Assessment:
Anuric u/o tol 7cc this shift. Foley dc
d yesterday due to persistent
fevers. BUN/Creat 62/9.0 (from 66/9.8). Received HD with Fluid
removal 3.2L transient hypotension.
Action:
Urine spec sent tor easoniphils.
Response:
unchanged.
Plan:
Straight cath q12hrs.
HD for ARF and fluid removal; next HD Monday
C. difficile infection (C Diff, Cdiff Colitis, Clostridium Difficile)
Assessment:
Flexiseal in place.
Action:
PO vanco x 14 day course (to end [**8-11**])
Response:
cont with loose stool per flexiseal
Plan:
[**Month (only) 51**] decrease po dose of vanco
** Spouse [**Name (NI) **] visited at bedside and phoned for updates; with good
understanding of pt
s status and plan of care. Will be in today to
visit.
|
Nursing
|
Classify the following medical document.
|
Admission Date: [**2144-7-1**] Discharge Date: [**2144-7-6**]
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / aspirin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 88 year old woman with a history of aortic
valvular repair/replacement, DM2, HTN, vertigo here s/p
unwitnessed fall with head injury and loss of consciousness. She
has no memory of the event or antecedent symptoms and appears
emotionally distressed by the event; she answered most questions
regarding the event with "I don't know." She has a posterior
headache with some abdominal upse, but no vomiting, visual
disturbances, or lethargy/ inability to stay awake. She denies
any other neurologic symptoms. She was found on imaging to have
small bifrontal SAH and small subcentimeter R frontal SDH.
Past Medical History:
Aortic valve repair/replacement (not known, [**12/2143**])
HTN
HL
DM2
Vertigo
?Arrhythmia
Social History:
No tobacco, ETOH, or illicits endorsed.
Family History:
NC
Physical Exam:
VS HR: 82 BP: 108/73
General: Awake, NAD, lying in bed comfortably.
Head: NC, superficial bleeding on posterior occiput, no scleral
icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Extremities: Warm, well perfused
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name, month, birth
date, place. Does not recall the event. Attention easily
attained
and maintained. Follows two step commands, midline and
appendicular. Language fluent with intact repetition and verbal
comprehension.
Normal prosody. No paraphasic errors. No dysarthria. No neglect.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to
confrontation. Funduscopy shows crisp disc margins, no
papilledema.
[III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to
light touch bilaterally.
[VII] No facial asymmetry. [VIII] Hearing intact to finger rub
bilaterally.
[IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength
5/5 bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ExD] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response silent bilaterally.
- Coordination - No dysmetria with finger/foot mirrored
movements.
- Gait - Not safe to assess.
Pertinent Results:
CT C-Spine [**7-1**]
IMPRESSION: No acute fracture or dislocation of the cervical
spine.
CT Head [**7-1**]
1. Bilateral subarachnoid hemorrhage.
2. 4-mm right frontal subdural hematoma without midline shift.
CT Abd/pelvis
No acute visceral injury in the abdomen or pelvis.
Mild anterolithesis of L4 over L5 of indeterinate age, but may
be
degenerative. Multi-level adjacent degenerative changes seen.
Cholelithiasis without CT findings of acute cholecystitis.
Apparent urinary bladder wall thickening, could relate to
underdistention, but recommend correlation with urine analysis.
CT head [**7-2**]
1. Thin right subdural hematoma, re-distributed posteriorly,
though unchanged in size with no significant mass effect.
2. Unchanged bifrontal subarachnoid hemorrhage.
3. Small focus of likely hemorrhagic contusion in the right
frontal region
inferiorly, which appears new from one day prior.
4. Newly noted layering of blood products within the occipital
horns of the lateral ventricles, likely reflecting
re-distribution. No hydrocephalus.
[**2144-7-3**] 08:40AM BLOOD TSH-5.7*
[**2144-7-4**] 02:35PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
Blood-MOD Nitrite-NEG Protein-30 Glucose-300 Ketone-10
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM RBC-42* WBC-11*
Bacteri-NONE Yeast-NONE Epi-<1
Brief Hospital Course:
Patient preented to [**Hospital1 18**] ER on [**7-1**] for eval after having a
witnessed syncopal episode in which she struck her head.
Imaging revealed a right frontal SDH and bifrontal contsuions.
She was on coumadin prior to admit so she was reversed with
vitamin K, factor 9, and FFP and admitted to the ICU for further
observation. She remained stable voernight in the ICU into [**7-2**]
and on the morning her INR was 1.5 for which she recieved a
single dose of Vitamin K PO in addition to her normal dosing,
she was also started on Dilantin for antiseizure prophylaxis.
She underwent a repeate head CT which showed normal evolution of
her bifrontal contusions as well as a new small amount of blood
in her occpital horns most likely due to redistribution of
blood. She was deemed fit for transfer to the floor and a
medicine consult was called to aid in a syncopal workup. A
follow-up INR was done which was 1.3 and after he tranfer to the
floor the medicine team saw her. They felt that she did not
require a TTE as she had one recently and given her lack of
symptoms pointing to a recurrent aortic stenosis as a culprit
they did not feel a new echo was warranted. She remained stable
on the floor on [**7-2**] and then in the evenign had a few episodes
of emesis which did not initially respond to zofran so phenergan
was added with good efect. On the morning of [**7-3**] medicine gave
further recs including orthostatic vital signs, medication
changes including adding evening lantus dosing for blood sugar
management, and IV fluids. She remained stable into the evening
of [**7-3**] with goals of mobilizing her and encouraging PO intake.
On [**7-4**] the patient was noted to be sundowning and to be
delerious. The medicine team made further recommendations in
regards to medications to avoid and started her on ceftriaxone
for a suspected UTI. A TSH was checked and was 5.6.
On [**7-5**] the patient was neurologically stable. Orthostatic VS's
were checked again and negative. The medicine team signed off
suggesting cefpodox for the UTI treatment x 10 days.
On [**7-6**] she was screened for rehab facilities. Her urine culture
resulted in no growth therefore her antibiotics were
discontinued. Now, DOD she is set for d/c to rehab and will
followup accordingly.
Medications on Admission:
Warfarin 10 on Thursday/Sunday and 7.5 other days, Metoprolol 25
[**Hospital1 **], Pravastatin 20, Ranitidine 150 [**Hospital1 **], Glargine (unknown
dose), Lispro (unknown dose), Meclizine PRN
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. insulin glargine 100 unit/mL Solution Subcutaneous
7. insulin lispro Subcutaneous
8. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for dizzy.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Right Subdural Hematoma
Bifrontal contusions
Syncope
Urinary tract infection
hyperglycemia
Elevated TSH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
ACCORDING TO YOUR CARDIOLOGIST YOU NO LONGER NEED TO TAKE
COUMADIN
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
- You are on dilantin and we recommend that you continue for
until your scheduled follow-up with Neurosurgery. This will
need to be monitored with blood work from your PCP or rehab
center.
?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
?????? You should follow up with your PCP upon discharge. It has been
recommended that you get a repeat TSH in [**3-25**] weeks.
Completed by:[**2144-7-6**]
|
Discharge summary
|
Classify the following medical document.
|
SICU
HPI:
70yo M w/ persistent abd pain, poor po intake, w/ gallstone
pancreatitis, complicated by abdominal compartment syndrome following
ERCP, ARDS, septic vasodilatory shock, Cdiff, and ARF. Now with
necrotizing pancreatitis s/p drain placement and multiple
necrosectomies.
.
SURGERIES:
ex lap ([**7-3**], [**7-3**])
partial abd closure ([**7-8**])
abd closure, GJ placement ([**7-13**])
vaccuum dressing ([**7-19**])
trach ([**7-24**])
vicryl closure ([**7-29**])
I&D retroperitoneal abscess ([**8-18**])
Minimally-invasive pancreatic necrosectomy ([**8-22**], [**8-28**], [**9-4**])
.
MICRO:
[**2113-7-3**]: Sputum: RARE YEAST
[**2113-7-8**] Sputcx: yeast w/ aspergillus
[**2113-7-8**] peritoneal: yeast 2+, [**Female First Name (un) **]
[**2113-7-11**] BAL: yeast, aspergillus
Cdiff: +
[**2113-7-19**] BALx2- prelim aspergillus
[**2113-7-25**] stool - guaic + [**2113-7-31**]
[**2113-7-25**] sputum: E.coli+yeast
[**2113-7-27**] Blood - GRAM POSITIVE COCCUS(COCCI)IN PAIRS AND CLUSTERS
[**2113-7-28**] BAL- Pan-S pseudomonas, cipro-R e.coli
[**2113-7-31**] sputum: pseudomonas + ecoli
[**2113-8-10**] cdiff neg x 3
[**2113-8-12**] blood cx P
[**2113-8-13**] pancreatic fluid culture: Pseudomanas and [**Female First Name (un) **] albicans
[**2113-9-4**]:[**Female First Name (un) 1354**]. Variable rods and gram positive cocci in chains and
clusters.
[**2113-9-5**] cdiff neg
[**2113-9-7**] BCx=coag neg staph and UCx Neg, L flank drainage - pseudomonas,
cipro and pip [**Last Name (un) 270**].
[**2113-9-7**] Wound Cx pseudomonas/ cipro-sensitive
[**2113-9-7**] Sputum +Pseudomonas and rare GNR
[**2113-9-9**] SputumCx: 4+(>10 per 1000X FIELD): GNR; 1+ Budding Yeast
[**2113-9-10**] UrineCx no growth
[**2113-9-11**] SputumCx: 4+ GNR, 2+ yeast
[**2113-9-12**] Picc Cath tip
IMAGING:
[**2113-7-1**]: RUQ US: limited study, gallbladder wall thickening, nl CBD, no
stones
[**2113-7-1**]: OSH CT abd/pelvis: thickened GB with stone in neck, can not
assess CBD, marked pancreatitis
[**2113-7-2**]: TTE and TEE ([**2113-7-2**]) showing hypovolemia, no wall motion
abnormalities.
[**2113-7-14**]: VUS: Non-obstructive clot in the left lower internal jugular
vein.
[**2113-7-14**]: Non-obstructive clot in the left lower internal jugular vein
[**2113-7-17**]: Liver U/S Cholelithiasis. Gallbladder wall thickening not
significantly changed. Small pericholecystic same as CT ([**2113-7-1**]). No
definite evidence cholecystitis.
[**2113-7-19**]: CT head/torso extensive pancreatic necrosis. No focal abscess.
Mild chronic sinusitis. R lobe PNA
[**2113-8-12**]: CT Torso necrotizing pancreatitis per [**Doctor First Name 213**] read
[**2113-8-21**]: Thrombosis L >RIJ, neither completely occluded. Complete
thrombosis R basilic vein which neither compresses nor augments.
[**2113-9-6**]: KUB paucity of abdominal gas. Residual barium throughout small
bowel, colon,rectum
[**2113-9-7**] CT abd: Interval decrease peripancreatic collection. Ascites,
unchanged. Small bilateral pleural effusions, atelectasis.
[**2113-9-8**]: CXR stable bibasilar atelectasis, effusions
[**2113-9-10**]: KUB = Contrast is seen in the transverse and descending colon.
hazy opacity projecting above the transverse colon ?extrav.
[**2113-9-10**] IJ Ultrasound = Small non-occlusive thrombosis in the distal
left IJ, smaller in size from prior. No new DVT.
[**2113-9-11**] CXR Moderate right pleural effusion, small left pleural effusion
and mild-to-moderate bibasilar atelectasis unchanged. Mediastinal
vascular congestion slightly improved.
[**2113-9-11**] KUB Contrast in transverse and descending colon
[**2113-9-12**] Renal US no hydronephrosis, stones or masses, arterial flow
documented bilaterally, limited exam cannot r/o R renal artery
stenosis, L kidney Doppler waveforms demonstrate good upstrokes however
lack of diastolic flow in the intraparenchymal arteries may be due to
technical limitations
[**2113-9-12**] KUB p
[**2113-9-12**] CXR p
.
EVENTS:
[**2113-7-2**]: ERCP, aspiration mid-procedure so intubated. Unsuccessful
ERCP, difficulty passing NG tube. Excessive air causing compartment
syndrome of abdomen. Taken to OR for Abd compartment syndrome from air
insufflation.
[**2113-7-3**]: Ex-lap, enterotomy for abd decompression. Due to worsening
[**Last Name (un) **] distension, hemodynamic instabilty the [**Last Name (un) **] wound was extended in
the ICU by the surgical team and packed. .
[**2113-7-8**]: to OR for washout + dressing change + partial closure, ABD
still open
[**2113-7-8**] Sputcx: yeast w/ aspergillus
[**2113-7-12**]: cdiff+, started po vanco, flagyl, dc vanco, zosyn.
[**2113-7-13**]: closed in OR
[**2113-7-17**]: Upper GI bleed, S/P Upper GI scope by GI and clipping of
bleeding vessel. Likely Dieulafoy's lesion.
[**2113-7-19**]: Head to pelvis CT - pancreatic necrosis, no evidence of large
hematoma or abscess. Developed hemoptysis w/ increased Gtube output ->
GI scoped - lots of debris in stomach, no evidence acute bleeding. TEE
- showing low svr state, hypovolemia, empty hyperdynamic ventricles.
Bronch showing erythematous trachea, bal for clot, thick secretions, no
plugs. Increasing abd distention with increased bladder pressures (28)
- OR for decompressive laporatomy. Vanco and zosyn for PNA.
[**2113-7-24**]: washout of abd wound and trach in OR
[**2113-7-28**]: Worsening infiltrates on CXR, bronch showing purulent fluid.
BAL sent. GPC to R SVC CVL. E.coli in sputum (pan-sensi). Lines
replaced w/ tips cultured. Vanco, zosyn, cipro added. Flagyl also added
for empiric C.diff. OR for closure w/ mesh. Trach with cuff leak, not
changed in OR.
[**2113-9-4**]: to OR for repeat necrosectomy, started levophed gtt, on CMV.
Left flank drain O/P bloody.
[**2113-9-5**]: 2 units PRBC, G/J changed in IR (tube was leaking), trach
collar trial
[**2113-9-6**]: Out of bed to chair, tube feeds re-started at 10 but bilious
vomiting several hours later, KUB ruled out obstruction, TF re-started
again
[**2113-9-7**]: TM trialx7h, CT A/P with PO unchanged per surgery, methadone 10
[**Hospital1 7**], started lopressor. T spike 101.6 ON--panCx and CXR.
[**2113-9-8**]: Bowel contents draining from wound around pancreatic drain. Pt
made NPO, TPN started. V/C/F started empirically.
[**2113-9-9**]: SputumCx 4+ GNR, 1+ yeast. Pancreatic drain dressing?
[**2113-9-10**]: Zosyn for ?pseudomonas, resent ET aspirate per ID as they did
not trust initial sputum/contam. KUB=+contrast still. Surgery wants
wet-dry [**Hospital1 7**] dressings, res and att aware of local breakdown [**2-6**]
fistula. IJ thrombi largely resolved on U/S. heparin gtt d/c'd.
[**2113-9-11**]: VAC change, Cr increasing to 3.3, Renal Reconsulted.
[**2113-9-12**]: New CVL, PICC pulled and sent for culture, A line placed. Abg
with 7.08 PCo2 81 HCO3 26 Lactate 1.2. Methadone held and placed on
rate - repeat gas 2 hrs later 7.08/81/153/23.
Assessment: 70M w/ gallstone pancreatitis s/p failed ERCP and abdominal
compartment syndrome([**2113-7-2**]) c/b vasodilatory SIRS shock w/subsequent
decompressive exploratory laparotomy ([**2113-7-3**]) w/ persistent open
abdomen, expansion of wound ([**2113-7-3**]) bleeding Dieulafoy's s/p clipping
([**2113-7-17**]) ARF, s/p episode ARDS and c.diff, s/p abd closure and repeat
decompressive ex lap ([**2113-7-19**]), now trached ([**2113-7-24**]), Partial closure
with mesh ([**2113-7-29**]) and wound Vac ([**2113-8-1**]). Repeatedly febrile, repeat
abd CT shows air in pancreas. now s/p drainage of pancreatic collection
by IR ([**2113-8-13**]) upsizing of drain ([**2113-8-18**]), laproscopic minimally
invasive pancreatic necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]).
.
PLAN:
Neuro: Methadone careful titration. Tylenol, Fentanyl prn pain.
CVS: Lopressor 5 IV Q6h as BP tolerates
Pulm: Follow CXRs. Changed to CMV for hypercabia.
GI: Significant drainage around pancreatic drain w. skin breakdown,
decreased since TF stopped. No drainage of perihep/gutter since not
loculated/acute. Per primary team low threshold for CT abdomen. KUB [**9-12**]
+ barium sigmoid. Small bowel follow through on hold. [**Doctor First Name **] wound care
plan is wet-dry [**Hospital1 7**] (too large for ostomy and aware of breakdown).
Renal: ARF, Cr 3.0 wtih FENA suggestive of primary renal etiology.
Renal Ultrasound limited Bl flow norm.
FEN: TF stopped [**2113-9-8**], TPN started (1.25g/kg prot; total [**Numeric Identifier **]). TPN +
LR IVF = 150. HyperP, hypoCa. No TPN phos. Corrected calcium normal.
Heme: Off heparin gtt for cleared neck U/S, on SCH. *PT REQUIRES ~8HRS
NOTICE FOR ANY BLOOD PRODUCTS [**2-6**] UNUSUAL ABS.
Endo: 20units regular in TPN. RISS.(normal [**Last Name (un) **] stim test [**2113-8-14**]). PTH
22
ID: V/C/Z for sensitive Pseudomonas+ pancreatic drainage. [**2113-9-7**]
BCx=coag neg staph and UCx Neg, L flank drainage - pseudomonas, cipro
and pip [**Last Name (un) 270**]. F/u PICC tip. Consider fungal coverage.
Wounds: Abdomen wound vac (changed [**9-11**]). Left flank wound around panc
tube. Wet->dry [**Hospital1 7**] per [**Doctor First Name 213**] att/res.
Prophylaxis: SCDs, H2B, SQH
Consults: West 2, ID, PT/OT, renal.
Code: Full
Disposition: SICU
Chief complaint:
Necrotizing pancreatitis
PMHx:
asthma, HTN, basal cell CA
Current medications:
Acetaminophen prn, Albuterol prn, Bisacodyl, Colace, Epoetin, Fentanyl
prn, Haloperidol prn, RISS, atrovent prn, Lorazepam prn, Protonix,
Elecrolyte SS, metoprolol 37.5mg po bid, methadone holding
24 Hour Events:
New CVL, PICC pulled and sent for culture, A line placed. Abg with 7.08
PCo2 81 HCO3 26 Lactate 1.2. Methadone held and placed on rate - repeat
gas 2 hrs later 7.08/81/153/23.
Post operative day:
POD#72 - ex lap for compartment syndrome. 2 drains to wall suction.
exam otherwise unchanged from previous.
POD#67 - s/p abdominal partial closure and dressing change
POD#61 - abdominal wound closure; insertion of g-j tube
POD#56 - ex lap
POD#51 - trach and abd washout
POD#46 - ex-lap and mesh closure of abdomen
POD#26 - Replacement of pancreatic drain for abscess including
irrigation port
POD#22 - laparoscopic pancreatic necrosectomy
POD#9 - washout of peripancreatic space.
Allergies:
Aspirin
Unknown;
Sulfa (Sulfonamide Antibiotics)
Rash;
Last dose of Antibiotics:
Vancomycin - [**2113-9-10**] 04:00 PM
Ciprofloxacin - [**2113-9-12**] 06:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2113-9-12**] 11:45 PM
Infusions:
Other ICU medications:
Methadone Hydrochloride - [**2113-9-12**] 10:08 AM
Heparin Sodium (Prophylaxis) - [**2113-9-12**] 10:05 PM
Metoprolol - [**2113-9-12**] 10:05 PM
Fentanyl - [**2113-9-12**] 11:45 PM
Other medications:
Flowsheet Data as of [**2113-9-13**] 01:08 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**16**] a.m.
Tmax: 36.9
C (98.5
T current: 36.9
C (98.5
HR: 82 (71 - 96) bpm
BP: 118/59(78) {116/55(75) - 133/66(87)} mmHg
RR: 20 (12 - 25) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 90.7 kg (admission): 108.3 kg
Height: 64 Inch
CVP: 14 (7 - 14) mmHg
Total In:
6,570 mL
238 mL
PO:
Tube feeding:
IV Fluid:
4,770 mL
166 mL
Blood products:
Total out:
2,974 mL
30 mL
Urine:
494 mL
30 mL
NG:
800 mL
Stool:
Drains:
1,680 mL
Balance:
3,596 mL
208 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 312 (312 - 412) mL
PS : 0 cmH2O
RR (Set): 18
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 43
PIP: 31 cmH2O
Plateau: 24 cmH2O
SPO2: 100%
ABG: 7.26/50/153/22/-4
Ve: 10.5 L/min
PaO2 / FiO2: 383
Physical Examination
Labs / Radiology
337 K/uL
8.1 g/dL
143 mg/dL
3.9 mg/dL
22 mEq/L
3.8 mEq/L
85 mg/dL
104 mEq/L
135 mEq/L
28.8 %
13.6 K/uL
[image002.jpg]
[**2113-9-7**] 03:18 AM
[**2113-9-8**] 04:25 AM
[**2113-9-9**] 03:00 AM
[**2113-9-10**] 03:09 AM
[**2113-9-11**] 03:00 AM
[**2113-9-11**] 05:25 PM
[**2113-9-12**] 02:25 AM
[**2113-9-12**] 07:20 PM
[**2113-9-12**] 08:12 PM
[**2113-9-12**] 10:04 PM
WBC
7.6
8.2
7.8
11.7
13.3
13.6
Hct
28.4
28.6
28.7
29.7
29.6
28.8
Plt
[**Telephone/Fax (3) **]94
358
337
Creatinine
2.0
2.0
2.1
2.2
2.9
3.3
3.5
3.9
TCO2
26
23
Glucose
237
143
93
159
146
133
174
143
Other labs: PT / PTT / INR:19.7/117.8/1.8, CK / CK-MB / Troponin
T:57/5/0.38, ALT / AST:[**10-20**], Alk-Phos / T bili:86/0.9, Amylase /
Lipase:51/16, Differential-Neuts:72.0 %, Band:6.0 %, Lymph:11.0 %,
Mono:5.0 %, Eos:1.0 %, Fibrinogen:738 mg/dL, Lactic Acid:1.2 mmol/L,
Albumin:1.7 g/dL, LDH:151 IU/L, Ca:9.0 mg/dL, Mg:1.9 mg/dL, PO4:6.0
mg/dL
Assessment and Plan
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name 11**]), AIRWAY, INABILITY TO PROTECT
(RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), [**Last Name 12**]
PROBLEM - ENTER DESCRIPTION IN COMMENTS, IMPAIRED SKIN INTEGRITY, RENAL
FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), VASCULAR DEVICE INFECTION
(NOT CENTRAL OR ARTERIAL LINE, INCLUDING GRAFT, FISTULA), SHOCK,
SEPTIC, ELECTROLYTE & FLUID DISORDER, OTHER, ANXIETY, .H/O DIARRHEA,
PANCREATIC PSEUDOCYST, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,
GAIT, IMPAIRED, KNOWLEDGE, IMPAIRED, TRANSFERS, IMPAIRED, ALTERATION IN
NUTRITION, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), .H/O FEVER
(HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), PAIN CONTROL
(ACUTE PAIN, CHRONIC PAIN)
Assessment and Plan: Neuro: Methadone careful titration. Tylenol,
Fentanyl prn pain.
CVS: Lopressor 5 IV Q6h as BP tolerates
Pulm: Follow CXRs. Changed to CMV for hypercabia.
GI: Significant drainage around pancreatic drain w. skin breakdown,
decreased since TF stopped. No drainage of perihep/gutter since not
loculated/acute. Per primary team low threshold for CT abdomen. KUB [**9-12**]
+ barium sigmoid. Small bowel follow through on hold. [**Doctor First Name **] wound care
plan is wet-dry [**Hospital1 7**] (too large for ostomy and aware of breakdown).
Renal: ARF, Cr 3.0 wtih FENA suggestive of primary renal etiology.
Renal Ultrasound limited Bl flow norm.
FEN: TF stopped [**2113-9-8**], TPN started (1.25g/kg prot; total [**Numeric Identifier **]). TPN +
LR IVF = 150. HyperP, hypoCa. No TPN phos. Corrected calcium normal.
Heme: Off heparin gtt for cleared neck U/S, on SCH. *PT REQUIRES ~8HRS
NOTICE FOR ANY BLOOD PRODUCTS [**2-6**] UNUSUAL ABS.
Endo: 20units regular in TPN. RISS.(normal [**Last Name (un) **] stim test [**2113-8-14**]). PTH
22
ID: V/C/Z for sensitive Pseudomonas+ pancreatic drainage. [**2113-9-7**]
BCx=coag neg staph and UCx Neg, L flank drainage - pseudomonas, cipro
and pip [**Last Name (un) 270**]. F/u PICC tip. Consider fungal coverage.
Wounds: Abdomen wound vac (changed [**9-11**]). Left flank wound around panc
tube. Wet->dry [**Hospital1 7**] per [**Doctor First Name 213**] att/res.
Neurologic:
Cardiovascular: Beta-blocker
Pulmonary: (Ventilator mode: CMV), PS trial
Gastrointestinal / Abdomen:
Nutrition: TPN
Renal: Foley, Poor UOP, RUS with normal renal artery flow bilaterally,
Rising Creatinine
Hematology:
Endocrine: RISS
Infectious Disease: Check cultures
Lines / Tubes / Drains: Foley, Trach, Surgical drains (hemovac, JP)
Wounds: Wound vacuum
Imaging: KUB today
Fluids: LR
Consults: General surgery, ID dept, Nephrology
Billing Diagnosis: Pancreatitis, Acute renal failure
ICU Care
Nutrition:
TPN w/ Lipids - [**2113-9-12**] 09:51 PM 75 mL/hour
Glycemic Control: Regular insulin sliding scale
Lines:
18 Gauge - [**2113-9-8**] 04:19 PM
Multi Lumen - [**2113-9-12**] 03:43 PM
Arterial Line - [**2113-9-12**] 08:45 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
Total time spent:
Patient is critically ill
|
Physician
|
Classify the following medical document.
|
Chief Complaint: septic shock
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:
42 y/o F w/CVID, Hep C cirrhosis, adm with C.diff sepsis.
24 Hour Events:
-head CT yest normal
-abd CT with ascites, edematous bowel but no pneumatosis
-tube feeds held due to worsening abd distention
-lactate normal
History obtained from Medical records
Patient unable to provide history: Sedated
Allergies:
Aspirin
rectal bleeding
Penicillins
Rash; Hives;
Sulfonamides
aseptic menigi
Biaxin (Oral) (Clarithromycin)
Diarrhea;
Levaquin (Oral) (Levofloxacin)
Rash;
Cefzil (Oral) (Cefprozil)
Rash;
Motrin (Oral) (Ibuprofen)
aseptic meningi
Erythromycin Base
Rash;
Last dose of Antibiotics:
Vancomycin - [**2189-3-19**] 06:33 AM
Metronidazole - [**2189-3-19**] 08:25 AM
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2189-3-18**] 03:57 PM
Dextrose 50% - [**2189-3-19**] 06:33 AM
Pantoprazole (Protonix) - [**2189-3-19**] 08:00 AM
Other medications:
vanco po, peridex, sodium chloride nasal spray, protonix, reglan,
insulin sliding scale, flagyl
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-3-19**] 10:22 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.6
C (97.8
Tcurrent: 36.2
C (97.1
HR: 94 (84 - 99) bpm
BP: 94/34(48) {85/30(46) - 114/51(64)} mmHg
RR: 23 (9 - 31) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 59.9 kg (admission): 64 kg
Height: 64 Inch
CVP: 14 (8 - 16)mmHg
Bladder pressure: 18 (18 - 18) mmHg
Total In:
2,881 mL
839 mL
PO:
TF:
453 mL
IVF:
806 mL
311 mL
Blood products:
Total out:
2,290 mL
535 mL
Urine:
2,290 mL
535 mL
NG:
Stool:
Drains:
Balance:
591 mL
305 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 350 (350 - 350) mL
Vt (Spontaneous): 113 (113 - 113) mL
RR (Set): 18
RR (Spontaneous): 0
PEEP: 5 cmH2O
FiO2: 40%
RSBI Deferred: RR >35
PIP: 11 cmH2O
SpO2: 96%
Ve: 10.8 L/min
Physical Examination
General Appearance: opens eyes to voice but doesn't follow commands
Eyes / Conjunctiva: icteric
Head, Ears, Nose, Throat: Normocephalic, trach in place
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: diffusely), tachypneic
Abdominal: Distended, doesn't appear tender but limited exam given
mental status
Extremities: Right: 3+, Left: 3+
Skin: Not assessed, Jaundice
Neurologic: No(t) Follows simple commands, Responds to: Verbal stimuli,
Movement: No spontaneous movement, Tone: Not assessed
Labs / Radiology
9.0 g/dL
228 K/uL
42 mg/dL
2.0 mg/dL
22 mEq/L
3.8 mEq/L
125 mg/dL
103 mEq/L
137 mEq/L
25.7 %
34.2 K/uL
[image002.jpg]
[**2189-3-15**] 04:21 AM
[**2189-3-15**] 05:01 PM
[**2189-3-16**] 03:43 AM
[**2189-3-16**] 03:16 PM
[**2189-3-17**] 04:53 AM
[**2189-3-17**] 03:37 PM
[**2189-3-18**] 05:00 AM
[**2189-3-18**] 07:43 AM
[**2189-3-18**] 05:17 PM
[**2189-3-19**] 05:40 AM
WBC
15.9
14.7
17.6
15.3
19.7
22.3
34.2
Hct
23.7
20.9
24.6
22.1
24.7
25.4
25.7
Plt
257
211
234
[**Telephone/Fax (3) 5338**]
228
Cr
1.8
1.2
1.5
2.6
1.5
1.6
1.6
2.0
2.0
TCO2
23
Glucose
76
60
50
66
199
186
185
163
42
Other labs: PT / PTT / INR:31.7/76.7/3.3, Differential-Neuts:87.0 %,
Band:2.0 %, Lymph:4.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6342 ng/mL,
Fibrinogen:260 mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.6 g/dL, LDH:339
IU/L, Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:4.4 mg/dL
Imaging: CXR: diffuse multifocal infiltrates, R hemidiaphragm more
clear today than yesterday
Microbiology: Sputum yest: abundant PMNs, no organisms on gram stain
Blood cx pending
Urine cx pending
Assessment and Plan
42 y/o F with multiple medical problems, critically ill for the past
month, now with worsening tachypnea, leukocytosis, abdominal
distention.
# Likely sepsis: Most likely source is abdomen given her physical exam
findings. No clear cause elucidated on abd CT yesterday but didn't
have contrast so wasn't a great study.
-add back antibiotics today (vanc/[**Last Name (un) **])
-repeat cx
-paracentesis
-check bladder pressure pre- and post-paracentesis - concern for abd
compartment syndrome; she certainly has intra abdominal hypertension
and would see if her BP and renal perfusion improves with paracentesis
-check LFTs, pancreatic enzymes
# Resp failure: Due to ARDS, likely component of volume overload.
Would hold on diuresis given what appears to be evolving sepsis.
# [**Last Name (un) **]: Unclear etiology, likely combination of ATN vs AIN. Will
follow. Creatinine was improving with diuresis suggesting some
improvement of her stroke volume with decreased R sided filling
pressures, but at this point would hold on diuresis as above. Could
also have worsening creatinine from vascular effects of high abdominal
pressures.
# Coagulopathy: Likely due to underlying liver disease and chronic
illness. No evidence of DIC.
ICU Care
Nutrition:
TPN w/ Lipids - [**2189-3-18**] 07:35 PM 50 mL/hour
Glycemic Control: Insulin in TPN, Comments: Decrease insulin in TPN
Lines:
PICC Line - [**2189-3-4**] 03:00 PM
Multi Lumen - [**2189-3-10**] 03:35 PM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
VAP: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: ICU consent signed Comments:
Code status: Full code
Disposition :ICU
Total time spent: 35 minutes
Patient is critically ill
------ Protected Section ------
I saw and examined this pt, and was present with the ICU team for the
key portions of services provided. I agree with Dr. [**First Name (STitle) **]
s note as
outlined above, and would add: Abd and Head CT negative yesterday. Pt
remains less responsive with worsening renal function (despite holding
of diuretics) and worsening leukocytosis.
Remain concerned for sepsis with abdomen the most likely source- back
on Vanco/Merepenem while we await pan-cultures. Bladder pressures
somewhat high (18-19) and will proceed with paracentesis today.
Pt is critically ill. Total time spent: 40 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 1174**] [**Last Name (NamePattern1) **], MD
on:[**2189-3-19**] 14:30 ------
|
Physician
|
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