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0,"Renal: Foley, Borderline UOP, follow up BUN and Creatinine"
1,Billing Diagnosis: Acute renal failure
2,Urine: 380 mL (24 hours)
3,Creatinine: 1.0 mg/dL
4,Nutren Renal (Full) - 45 mL/hour
5,Nephrology consult
6,Heart rhythm: AF (Atrial Fibrillation)
7,Cardiovascular: (Rhythm: Irregular)
8,"Cardiovascular: Beta-blocker, Afib"
9,HR: 94 (88 - 111) bpm
10,Metoprolol Tartrate
11,s/p OLT c/b b/l PTX (?diaphragmatic injury) and fluid management issues secondary to massive ascites
12,Billing Diagnosis: Post-op complication
13,Billing Diagnosis: Respiratory distress: Insufficiency / Post-op
14,s/p R doxy pleurodesis
15,s/p R talc pleurodesis
16,Multi Lumen line placed
17,DM
18,Glycemic Control: Regular insulin sliding scale
19,Endocrine: RISS
20,Glucose: 151 mg/dL
21,Glucose: 117 mg/dL
22,Insulin (in medication list)
23,"EtOH cirrhosis c/b encephalopathy, ascites, splenomegaly"
24,PSC (Primary Sclerosing Cholangitis)
25,s/p OLT (orthotopic liver transplant)
26,?HCC
27,ALT / AST:13/14
28,Alk-Phos / T bili:107/0.3
29,Albumin:2.6 g/dL
30,b/l PTX (?diaphragmatic injury)
31,s/p R doxy pleurodesis
32,s/p R talc pleurodesis
33,Chest tube - pleural
34,"OLT, bilateral pleurodesis (chief complaint)"
35,Respiratory / Chest: (Breath Sounds: Rhonchorous : Bilateral)
36,O2 Delivery Device: Trach mask
37,CXR today
38,"Differential-Neuts:94.0 %, Lymph:1.0 %"
39,Tmax: 35.8 C (96.5)
40,WBC: 2.4 - 5.0 K/uL
41,Lactic Acid:1.1 mmol/L
42,Fluconazole / Valgancyclovir (antibiotics given)
43,Heparin Sodium (Prophylaxis)
44,BP: 101/66(74) {97/50(67) - 129/87(98)} mmHg
45,Lactic Acid:1.1 mmol/L
46,Borderline UOP
47,Urine: 380 mL (24 hours)
48,Balance: 166 mL (24 hours)
49,CKD: Cr baseline 2.0. Currently 2.3 w/ oliguria.
50,Cr 2.3 w/ oliguria
51,"continue to monitor renal fx, renally dose meds, avoid nephrotoxins."
52,"Urine: 2,210 mL (24 hours)"
53,NovaSource Renal (Full) - 120 mL/hour
54,Balance: -186 mL (24 hours)
55,HR: 60 (56 - 85) bpm
56,Heart rhythm: SR (Sinus Rhythm)
57,s/p tracheostomy placement with R sided PTX and difficulty with ventilation now s/p chest tube placement and removal
58,Bronch showed posterior invagination of tracheal tissue blocking trach which improved with increased PEEP
59,IP advanced trach but did not offer stent based on other comorbidities
60,admitted from rehab s/p tracheostomy placement with R sided PTX
61,22 Gauge - line placed
62,Trach was changed to 12 cm yesterday
63,DM: RISS with lantus 8u qhs per family's request for change
64,Glycemic Control: Regular insulin sliding scale
65,"have changed lantus to qhs, also have changed to 8 units"
66,Glucose: 138 mg/dL
67,Glucose: 195 / 288 / 292 / 217 / 93 / 138
68,Hypernatremia: Increase OG free water flushes now 250cc q4h.
69,"sodium checked and was 148, free H20 flushes increased from 150cc --> 200cc q4hrs"
70,147 mEq/L (sodium)
71,Balance: -186 mL (24 hours)
72,"Mg++:2.6 mg/dL, PO4:2.9 mg/dL"
73,Ca++:9.5 mg/dL
74,BP: 151/68(89) {96/41(54) - 197/86(111)} mmHg
75,CKD: Cr baseline 2.0. Currently 2.3 w/ oliguria.
76,HR: 60 (56 - 85) bpm
77,CKD: Cr baseline 2.0. Currently 2.3 w/ oliguria.
78,Cr 2.0 / 2.0 / 2.1 / 2.1 / 2.3 / 2.4 / 2.3 (trending creatinine)
79,"continue to monitor renal fx, renally dose meds, avoid nephrotoxins."
80,NovaSource Renal (Full) - 120 mL/hour
81,"Urine: 2,210 mL (24 hours)"
82,O2 Delivery Device: Tracheostomy tube
83,Ventilator mode: CPAP/PSV
84,Respiratory distress: s/p tracheostomy replacement at rehab
85,Right sided PTX improved and CXR stable since CT removed
86,admitted from rehab s/p tracheostomy placement with R sided PTX
87,s/p chest tube placement and removal
88,spontaneous vs. due to vigorous ventilation at rehab vs. right pneumothorax in the setting of recent bronchoscopy
89,O2 Delivery Device: Tracheostomy tube
90,Ventilator mode: CPAP/PSV
91,PEEP: 14 cmH2O
92,chronic respiratory failure with trach/PEG
93,Respiratory distress: s/p tracheostomy replacement at rehab
94,"Continue pressure support trial, attempt PEEP to 14"
95,Ventilator mode: CPAP/PSV
96,FiO2: 40%
97,SpO2: 100%
98,RR: 20 (14 - 25) insp/min
99,Urine: 120 mL
100,"With 2.7 L IVFs, lactate improved to 4.1"
101,"Total out: 120 mL, Balance: 1,173 mL (positive fluid balance with oliguria)"
102,Cr: 1.1 mg/dL
103,BUN: 38 mg/dL
104,"Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis"
105,"HR in 70-80s, ?junctional at one point"
106,"pt was found to be pulseless, received CPR for 20 seconds"
107,"Possible dysrhythmia, cardiac arrest (less likely) or neurological event"
108,Heart rhythm: SR (Sinus Rhythm)
109,HR: 62 (58 - 74) bpm
110,"Cardiovascular: (S1: Normal), (S2: Normal)"
111,COPD (per records)
112,"Ventilator mode: CMV/ASSIST, Vt (Set): 400 mL"
113,Respiratory / Chest: (Breath Sounds: Clear)
114,O2 Delivery Device: Endotracheal tube
115,heavy atherosclerotic disease of coronaries and aorta
116,cardiomegaly with marked right atrial enlargement
117,Murmur: Systolic
118,CK / CKMB / Troponin-T:146/6/0.13
119,"Cardiovascular: No(t) Chest pain, No(t) Palpitations"
120,TropT: 0.13
121,"(Right radial pulse: Present), (Left radial pulse: Present)"
122,Hypercholesterolemia
123,heavy atherosclerotic disease of coronaries and aorta
124,Albumin:2.9 g/dL
125,Hypertension
126,Initial blood pressures were up to 224/150 briefly
127,BP: 125/60(75) {83/47(56) - 125/65(75)} mmHg
128,then settled in 90s/50s
129,DVT: Boots(Systemic anticoagulation: None)
130,hyponatremia (thought [**3-17**] SIADH)
131,HYPOCALCEMIA -- Replete. Monitor ionized Ca++.
132,Ca++:6.3 mg/dL
133,Lactic Acid:2.4 mmol/L
134,112 mEq/L (chloride)
135,4.2 mEq/L (potassium)
136,"Mg++:2.1 mg/dL, PO4:4.0 mg/dL"
137,LFT ELEVATION -- unclear etiology. Possibly shock liver from hypotension.
138,"Plan to trend serial LFTs, check amylase, lipase. Consider RUQ U/S."
139,LDH:1556 IU/L
140,Alk Phos / T Bili:34/0.6
141,gallstones
142,Albumin:2.9 g/dL
143,"bilateral pleural effusions, R>L (CT torso)"
144,recently admitted for bilateral pleural effusions
145,PEEP: 5 cmH2O
146,Respiratory / Chest: (Breath Sounds: Clear)
147,RR: 16 (16 - 20) insp/min
148,"CT torso showed bilateral pleural effusions, R>L"
149,"recently admitted for weakness, poor po intake, fever, and bilateral pleural effusions"
150,Respiratory / Chest: (Expansion: Symmetric)
151,Respiratory / Chest: (Breath Sounds: Clear)
152,SpO2: 100%
153,She was diagnosed with pneumonia and treated with levofloxacin
154,Pt received vanc/zosyn
155,"No evidence for pneumonia/ infection, sepsis, pulmonary embolism"
156,No secretions suctioned from ETT
157,Temp was 99.8 rectally
158,"Differential-Neuts:85.0 %, Band:0.0 %, Lymph:10.0 %"
159,RESPIRATORY FAILURE -- unclear precipitant. Intubated for agonal breathing.
160,pt was noted to have agonal breathing. She was immediately intubated.
161,PULSELESS ARREST -- Unclear whether related to precipitant for admission
162,"Plan continue mechanical ventilation, adjust working towards SBT and extubation"
163,Ventilator mode: CMV/ASSIST
164,ABG: 7.39/42/77/26/0
165,SpO2: 100%
166,PaO2 / FiO2: 154
167,FiO2: 50%
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