| row_id,text | |
| 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% | |