START_OF_RECORD=1||||1|||| O: 58 YEAR OLD FEMALE ADMITTED IN TRANSFER FROM [**Hospital 1**] FOR MENTAL STATUS CHANGES POST FALL AT HOME AND CONTINUED HYPOTENSION AT [**Hospital 1**] REQUIRING DOPAMINE; PMH: CAD, S/P MI [**1994**]; LCX PTCA; 3V CABG WITH MVR; CMP; AFIB- AV NODE ABLATION; PERM PACER- DDD MODE; PULM HTN; PVD; NIDDM; HPI: 2 WEEK HISTORY LEG WEAKNESS; [**04-18**] FOUND BY HUSBAND ON FLOOR- AWAKE, BUT MENTAL STATUS CHANGES; TO [**Hospital 1**] ER- TO THEIR ICU; HEAD CT- NEG FOR BLEED; VQ SCAN- NEG FOR PE; ECHO- GLOBAL HYPOKINESIS; EF EST 20%; R/O FOR MI; DIGOXIN TOXIC WITH HYPERKALEMIA- KAYEXALATE, DEXTROSE, INSULIN; RENAL INSUFFICIENCY- BUN 54, CR 2.8; INR 7 ( ON COUMADIN AT HOME); [**04-19**] AT [**Last Name (un) **]- 2 FFP, 2 UNITS PRBC, VITAMIN K; REFERRED TO [**Hospital1 2**]. ARRIVED IN TRANSFER APPROX. 2130; IN NO MAJOR DISTRESS; DOPAMINE TAPER, THEN DC; NS FLUID BOLUS GIVEN WITH IMPROVEMENT IN BP RANGE; SEE FLOW SHEET SECTION FOR CLINICAL INFORMATION; A: NO HEMODYNAMIC COMPROMISE SINCE TRANSFER; TOLERATING DOPAMINE DC; P: TREND BP RANGE; OBSERVE FOR PRECIPITOUS HYPOTENSION. ||||END_OF_RECORD START_OF_RECORD=1||||2|||| O: BUN NOW 50; CR 2.1- URINE OUTPUT IMPROVING SLIGHTLY POST FLUID CHALLENGE; K 3.9; A: CONTINUED RENAL INSUFFICIENCY/ RENAL FAILURE. P: FOR REPEAT BUN,CR,K; CONTINUE I&O. ||||END_OF_RECORD START_OF_RECORD=1||||3|||| O: INR 2.0; PT 17.5; PTT 32.3; IV HEPARIN BEGUN AT 1100 UNITS POST BOLUS; 5 MG COUMADIN GIVEN. A: ANTICOAGULATION BEGUN FOR HISTORY OF MECHANICAK VALVE, HISTORY OF AFIB; P: MAINTAIN IV HEPARIN PER PROTOCOL; FOR AM PT, PTT. ||||END_OF_RECORD START_OF_RECORD=1||||4|||| 58 YR OLD ADMITTED TO [**Last Name (un) **] HOSPIATAL P FALL C MENTAL STATUS CHANGES REQUIRING DOPAMINE . CT SCAN NEG . R/O MI , VQ SCAN NEG, HYPERKALEMIA RX C KAYEXALATE PMH MI [**94**], 3 VCABG C MVR,ON COUMADIN, EF 20% ,AV NODE ABLATION FOR A FIB, DDD PERM PACER , PULM HYPERTENSION ,PVD, NIDDM ,2 WKS LEG WEAKNESS TRANS TO [**Hospital1 2**] [**04-19**] .DOPAMINE WEANED TO OFF . PLAN TO RESTART CARDIAC MEDS ,ADVANCE ACTIVITY, TRANS TO FLOOR. CV PACED R. NO ECTOPY . BP STABLE OFF DOPAMINE,OOB TOL WELL . DIG RESTARTED . HEPARIN DECREASED TO 900 U FOR PTT 119 . COUMADIN HAS BEEN RESTARTED . LEGS EDEMATOUS RESP RALES IN BASES ,EXERTIONAL WHEEZES . DOE. SAT 94 TO 96 ON 3LNP GI PASSING LOOSE BR STOOL .APPETITE POOR .NOT REQUIRING SSRI FOR BP GU CL YEL VIA FOLEY 50 CC HR ,LASIX GIVEN . K 3.8 NO RX AT THIS TIME NEURO AOX 3 MAE . SKIN RED RASH GROIN, NYSTATIN POWDER ORDERED APPROACHING BASELIN CARDIAC FX MONITOR BP C DIURESIS FOLLOW K ||||END_OF_RECORD START_OF_RECORD=1||||5|||| ccu nsg admission note: 12 am-- pt is a 57yo f who is followed at [**Hospital1 **] by dr [**Last Name (STitle) 3**]. she arrived a&ox3 via amb from [**Hospital1 4**] ew for further eval/monitoring. today pt was at home and states that her legs felt weak and she fell to the ground striking her head on the kitchen floor. pt states that she did not have loc. 911 was called and pt taken to [**Hospital 4**] hosp. she sustained a lac to the back of her head that was sutured. she did rec tet [**Name6 (MD) 5**] per rn. per report she has been a&ox3. she had labs drawn which showed inr to be 24, hct 25.4, na 132, k 5.1, dig 2.4 w/elevated bun/creat. she had head ct done which was reported to be neg. she was also noted to have bp that dropped to 70's--pt cont'd a&ox3, she was started on dopa up to 8mcg, she was given 1 unit ffp. she was transfered to ccu for further monitoring. pt states that for the past few weeks she hasn't been feeling well. states that she has been having swelling in her abd that has caused her to lose her appetite. she has not been eating/drinking that well, also notes decreased u/o over the past few weeks. she has also had increased swelling to her lower ext which she states makes it harder to amb. she did fall 1 noc ago but did not sustain any injury at that time. she has been having problems w/loose stools for the past few weeks as well and states that she has had several tests done on stool which have been neg, she was taking imodium for diarrhea but it has not been working and has started a new med which she can't recall. states that she has been having her inr followed and has been taking coumadin as instructed. she has only noted bleeding from hemrroids. ros-- neuro--a&ox3, mae, skin w&d, c/o pain to back of head. head w/sutures, no bleeding from site at this time resp--ls w/crackles at bases, cta in upper lobes, sat on 5l 98%, rr 16 not labored, no c/o sob cardiac--hr 70's av paced, arrived on 7mcg of dopa, bp 90-100/40's, no c/o cp gi--abd obese, firm/distened, (+)bs, did pass sm amt of brown stool, no c/o abd pain at this time gu--pt states no void since 3pm, feels like she has to void, foley placed for 50cc dark yellow urine skin--area of ecchymosis to r shoulder/upper arm, does also have other areas of bruising to arms/legs, skin to back/buttocks intact access--arrived w/2 #22 iv's to r arm, #18 ac placed and bloods resent social--pt married, lives in [**Location 6**], husband did not come to [**Hospital1 **] w/pt, he is aware that she is here ||||END_OF_RECORD START_OF_RECORD=1||||6|||| nsg note cont'd: pmh: cad--s/p mi '[**94**] s/p cabg/mvr '[**97**] s/p pacemaker-ddd s/p aflutter/afib htn dm high chol pvd--claudication depression uterine bleeding pre-renal azotemia all: ceclor meds: aldactone---asa atenolol---lipitor coreg---coumadin dig---enalapril gemptbrozil---lasix ativan---micro-k trazadone---zoloft amiodarone s: "i have a headache" o: neuro--pt remains a&ox3, asking for tylenol for c/o headache from lac, scant amt of bleeding noted on pad behind head resp--ls w/crackles at bases, conts w/out any c/o diff breathing, sat on 5l 98-100%, rr 18-20 not labored cardiac--hr conts av paced, conts on 8mcg of dopamine, no adjustments made, bp 90-101/50, repeat inr on arrival 5.7, will re-check labs this am gi--abd obese, (+)bs, has been on/off bed pan 2-3 times w/out any results, does have sm amt of old blood on rectum which pt states are from hemrroids gu--foley patent, draining approx 30-40cc/hr, team aware, will recheck bun/creat this am skin--conts w/areas of ecchymosis to arms/r shoulder, does have petachae to lower ext a: alt co d/t heart failure p: cont dopamine for bp control, wean as tol monitor fluid status, ?needs swan follow labs, monitor for bleeding ||||END_OF_RECORD START_OF_RECORD=1||||7|||| S-"When can I go home?" O-Neuro alert and oriented x3, pleasant but uncomfortable most of day. c/o headache treated with tylenol #3 q6hrs with relief. Received versed .5mg IVB during PA catheter placement. Asking appropiate questions about POC and hopefull to feel better to go home soon. CV-remained hypotensive all day unable to wean dopamine. At 8:30am SBP 80 and dopamine gtt increased to 9.5mg/kg. PA catheter placed under fluro with opening # PA 70/38 PWP 40 with V waves to 50, CVP 28 with V waves to 38, CO/CI/SVR 7.5/3.5/437. Started Dobutamine at 5mcg/kg without change in VS/PAD, increased to 7.5--10mcg/kg by 6pm. Epsiode of hypotension with gtts disconnected transiently. Presently at 6pm Dopamine at 12mcg/kg and Dobutamine at 10mcg/kg with PAP 58/27 CVP 29. Aline placed LRA with MAPS borderline 56-63. HR 70 AV paced with occ PVC's. Received 1 unit FFP for INR 7.0 decreased to 3.3 and received 2nd unit during PA insertion. Resp-rr 20-24 LS rales 1/3 up bilaterally O2 sats 95-98% on 5l np. GU-foley draining 20-30cc/hr concentrated urine. GI-abd remains distended +acsites tender to touch. No diarrhea, NPO until after PA catheter. Tolerated well. C/o burning from lying flat for PA catheter. HCT 24.7 received 1 unit PRBC. Skin-lac on back of head cleansed, no drainage from site. Eccymosis on right shoulder/arm. Social- husband and daughter into visit. ||||END_OF_RECORD START_OF_RECORD=1||||8|||| nsg progress note 7p-7a: neuro--a&ox3, c/o's of being uncomfortable w/back pain, turning s-s throughout the noc, given trazadone for sleep and then asking for ativan, given 1mg w/gd effect resp--ls w/crackles at bases, cta in upper lobes, conts on 5l w/sat 93-99%, rr 20's, states that she does have some sob but no different than how she felt when admitted, abg wnl cardiac--hr av paced at 70's w/occ pvc, pa# 63-70/27-30, cvp 28-31, unable to wedge d/t overwedging, conts on doubutamine/dopamine, gtts titrated throughout the noc, dobutamine as high as 15mcg, co 6.9-9.1, ci 3.22-4.25, svr 272-359, team aware that co increasing & svr decreasing, so dobutamine titrated down, now at 8.0mcg, dopamine up to 18mcg w/bp 85-101/40's w/map 58-60, team aware of increased dopamine, did rec 40mg iv lasix w/min response initially of 80cc, rec'd 2nd unit of prbc's for hct of 23, inr 2.7 gi--abd conts firm/distended, (+)bs, states that she has sensation that she has to move bowels but no stool tonight, asking for supp to help move bowels, gu--foley to gravity, hematuria initially but clearing up during noc, u/o 60-120cc/hr, conts to have discomfort w/cath, lido jelly applied around cath site w/temporary relief of discomfort, also started pyridium skin--conts w/bruising, c/o pain to buttocks, pt has ecchymosis to coccyx, no breakdown noted, states that she did fall and land on buttocks prior to admission, turning s-s to get comfortable, 1st step to get put on bed ||||END_OF_RECORD START_OF_RECORD=1||||9|||| S-"I wish they could find out whats wrong with me." O-Neuro alert and oriented x3, more talkative today. c/o anxiety from all the testing and asked for ativan x2. Received ativan .5mg IVB x2. ALso c/o slight headache, not as bad as yesterday, received tyelnol #3 x2 with relief. PEARL head lac sutures intact/ no drainage. CV-Hemodynamics remain unclear. CVP remains elevated at 28-30 and no change in PAD/PWP despite dopamine/dobutamine. O2 sat run done this am revealed CVP 65, VIP CVP 73, PA 72, PWP 93, Art 97%. Stat echo to r/o A or V shunt which was negative. Echo revealed severe TR unable to quantify severity of MR [**Last Name (Titles) 7**]/t MVR, LVEF <20%. Hemodynamics FICK CO/CI/SVR 10.1/4.72/230 c/w TD CO 5.17 (although waveform appeared dampened). MAPs low 54-62 on dobutamine/dopamine and plan to wean over to neo gtt. By 3pm dobutamine weaned off and dopamine wened down to 8mcg/kg SBP dropped to 70's and neo added. BY 5pm dopamine off but requiring 320mcg of Neo and so Dopamine restarted at 5mcg/kg. MAPs now 75-78. PLan to check hemodynamics at 8pm. Resp-rr 18-24 O2 sats 91-98% depending on sleeping when sats drop to 91%. LS rales at bases, no cough.ABG 91/42/7.36/25/-1. Occ periods of SOB possibly related to anxiety. When flying flat face does become cyanotic fairly quickly. ID-Afebrile temp 97-98% WBC 7.6 Plan for diagnotic paracentesis this eve. Plan to send blood cultures this eve also. GI- HCt remained low despite 2u PRBC 24.2 received 2 more units PRBC each over 4 hours. HCT to be check at 8pm. CAT scan of abd completed without contrast, revealed ascitis with gall stones no bleeding noted on preliminary assessment. Occ periods of nausea relief spont. Had feelings of having a BM but unable to, until about 5pm when she had 2 episodes of melanotic stools, 2nd stool about 100cc strongly OB+. NPO except clear liquids. Plan for NGT/lavage this eve and possibly EGD if neccesary. Abd is tense with ascitis. GU-foley draining moderate amt 50-100cc/hr clear amber/orange urine. At 4pm pt noted that she had wet the bed and found pt with a moderate amt of urine leak around foley. Noted urine darker with small clots. Manual lavage with 500cc NS and removed ~6 large sized clots. Replaced foley with #20fr 3way foley and started GU irrigation at 200cc/hr to keep urine free from clots with good results. Urine color cherry colored. Skin-petechiae over most of upper extremities still present. Eccymosis right shoulder/arm. Social-husband in visiting and spoke with MDs about POC. ||||END_OF_RECORD START_OF_RECORD=1||||10|||| O: afeb. HR 70 paced. BP 104-115/50's. remains on neo at 320mcq and dopa at 5mcq. PAP 60's/27-30, wedge 28, CVP 27-29. C.O. 6.1/2.8/616 , SVR down to 538 at 0600. mixed venous PAsat down to 53-55 off dobutamine gtt. HO aware. no intervention. remains off dobut. - LS crackles bases. sats 92-94% on 5lNC. dyspneic with turing, movement. resolves with rest. - u/o averaging 100cc/hr. GU irrigant inc. to 300cc in eve d/t clots in foley, currently urine is clear and orange d/t pyridium. GU irrigant at 200cc/hr at 0600. - repeat HCT 32 at 2100. am pnd. no stool. - ABD u/s done at bedside and paracentesis was performed. ~ 400cc clear liq. asicits fluid taken off. sent for cx. - following that procedure and allowing for rest, team placed NGT. found coffee grounds that cleared after ~ 300cc. NGT removed. pt. med. with total .75mg versed IV for both procedures. tol. well. - also given trazadone and po ativan for sleep and able to sleep well for ~ 6hours. woke alert, approp. A: SVR improved on neo. PA sat down improved u/o. hematuria resolved with irrigation PAP's unchanged asicitis removed via guided U/S. coffee grounds lavaged. P: follow hemodynamics, PAP's. ? wean neo as tol. monitor Sats, C.O. and SVR. follow u/o and GU irrigation. ||||END_OF_RECORD START_OF_RECORD=1||||11|||| NEURO: A&O X3. MAE. COOPERATIVE. RESP: O2->3L NP. O2 SATS 93->89%. O2 INCREASED TO 4L NP. O2 SATS 94- 100%. ABG 7.4/40/100/26 O2 SAT 97%. RR 15-19. BS CLEAR BUT DIMINISHED AT BASES. CARDIAC: HR 71 AVP. BP 91-102/45-52. PAD 29->23, CVP 31->24, W 17 ON DOPA 7.9MCG/KG. CO PENDING. GI: TOL. CLEAR LIXS WELL. ABD. DISTENDED WITH ASCITES. BS HYPOACTIVE. NO STOOL DESPITE BEING PLACED ON BEDPAN 6-8 TIMES. GU: 3 WAY FOLEY IN PLACE & DRAINING ORANGE COLOR URINE D/T PYRIDIUM. GU [**Last Name (un) 8**]. STOPPED AT 2130 & NO CLOTS SEEN. URINE DOES APPEAR TO HAVE INCREASED SEDIMENT. U/O 100-200CC/HR. GIVEN LASIX 80MG IV X1. ID: AFEBRILE. ENDOCRINE: BS 112. AM LABS PENDING. ||||END_OF_RECORD START_OF_RECORD=1||||12|||| NEURO: A&O X3. RESP: O2->2L NP. O2 SATS 92-95%. RR 15-22. BS CLEAR BUT DIMINISHED AT BASES. ABG 7.43/41/76/28 WITH O2 SAT 96%. MIXED VENOUS O2 61. CARDIAC: HR 71 AVP. BP 100-108/49-57. PAD 25-31, CVP 26-30, & CO 5.8/2.71/497 ON DOPA 9MCG/KG. GI: ADB. WITH ASCITES. BS HYPOACTIVE. 3 SM. STOOLS (LOOSE BLACK),G+. GU: FOLEY CATHETER->CD DRAINING ORANGE COLOR URINE D/T PYRIDIUM. C/O BURNING WITH CATHETER & WANTS IT REMOVED TODAY. U/O 80-360CC/ HR. ID: AFEBRILE. ENDOCRINE: BS 129. NO INSULIN REQUIRED. LABS: WBC 7.4, HCT 29.6, & PLAT CT 150K. CHEMISTRIES PENDING. ||||END_OF_RECORD START_OF_RECORD=1||||13|||| S- " CAN I GET UP TO THE WHEELCHAIR...CAN I GET UP TO A CHAIR.." O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAINS WITH BP- 100-120/40-60. HR- 70'S AV PACED. NO VEA- LYTES WNL AFTER EARLIER REPLACEMENT. REMAINS DOPA DEPENDANT ON 7 MCG/KG- WITH ANY INTERRUPTION IN GTT- BP DROPS TO 70-80'S/ CO/CI/SVR REMAINS AT BASELINE WITH 5.5/2.5/450 HOLDING EVENING CAPTOPRIL FOR SEVERELY LOW SVR, LABILE BP OFF/DOPA DEPENDANCE. INCREASED ACTIVITY TO DANGLE ON EDGE OF BED X 15-20 MINUTES - TOLERATED WELL, BUT VERY EXHAUSTED AFTERWARD- ENCOURAGED TO REST/PACE ACTIVITIES. RESP- CRACKLES AT BASE- O2 SATS- 92% ON 2 L AFTER ACTIVITY- INCREASED TO 4 L NP WITH IMPROVED O2 SATS. DIURESING TO 80 LASIX - 100-200/HOUR. I/O (-) 1300CC AS OF 10PM.. TACHYPNIC WITH ANY EXERTION, BUT COMFORTABLE CURRENTLY RESTING. ID- AFBRILE. NO SIGN INFECTION. GI- GIVEN MOM - NO RESULTS AS OF YET, NO CALL FOR BEDPAN THIS SHIFT- NO FURTHER DIARRHEA.EATING SMALL AMTS SHERBET/TEA/CRACKERS. MUCH ABDOMINAL DISTENSION/ACSITES. GU- GOOD U.O- VIA FOLEY CATHTER- URINE ORANGE S/P PYRIDIUM. NO SIGN CLOTS/NEED FOR IRRIGANT. SKIN- REDDENED COCCYX- ENCOURAGED TO TILT ON SIDE- COMPLETELY NOT COMFORTABLE IN THIS POSITION, MOVING BACK TO MIDDLE OF BED. TURNED WITH 2 ASSIST. SEE ABOVE FOR INCREASE ACTIVITY. HEME- REMAINS OFF HEPARIN/COUMADIN WITH ELEVATED INR- NO REPEAT INR/COAGS CHECKED. MS- PT ASKING TO GET OOB- RESTLESS, EXPLAINED NEED FOR PA LINE, REASON FOR CERTAIN MEDS/TREAMENT PLAN ETC. APPEARS TO UNDERSTAND AND MORE COMFORTABLE AFTER MOVING AROUND AND EXPLAINING NEED FOR DECREASED MOBILITY WITH PA LINE, LABILE BP/ DOPA GTT. HUSBAND IN TO VISIT FOR COUPLE OF HOURS. Patient upset learning about death of son A/P - PT WITH HEART FAILURE/LABILE BP/LOW SVR CURRENTLY TOLERATING DIURESIS/DOPA THERAPY. CONTINUE TO AGGRESSIVELY DIURESE- GOAL (-) 1-2 LITERS/DAY. WATCH GI FOR ANY NEED FOR MORE MOM/LAXATIVES. SKIN CARE/COMFORT. CLOSELY WATCH LYTES/REPLETE AS NEEDED. CONSIDER ADDING VERY LOW DOSE CAPTOPRIL ONCE BP LESS LABILE/SVR NOT AS LOW. PA LINE D/C ONCE MEDS ARE OPTIMIZED. ||||END_OF_RECORD START_OF_RECORD=1||||14|||| S: " Can I get out of bed? " O: pt. slept through night well, woke ~ 0400, wanting to get OOB to commode. explained to pt. reason she is not ready or strong enough to get OOB at this time. refused bedpan. passing gas. no VEA. BP 92-119/50's. PAP's unchanged: 60's/27-30, CVP 25-27. C.O. 5.9/2.7/569. - u/o 80-100/hr. neg. 1.3L at 12am. neg. 400cc at 0600. no lasix tonight. LS crackles at bases. denies SOB. RR 16-20 when asleep, up to 20's with any activity. sats 95-97% on 4lnc. A: stable hemodynam. with no change from diuresis. P: continue dopa at 9mcq., wean per team. continue diuresis, monitor lytes, HCT. continue stool softener, laxative prn. ||||END_OF_RECORD START_OF_RECORD=1||||15|||| CCU NPN: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA. CARDIAC: DOPA WEANED TO 5MCG/KG/MIN MAINTAINING MAPS GREATER THAN 60. ALSO ABLE TO GIVE CAPTOPRIL 6.25 AT 11 AND 6PM. IN ADDITION ALSO DIURESED WITH 80MG LASIX AND CURRENTLY NEGATIVE BY 1500CC. SWAN NUMBERS PA 60/30 PCWP 30 CVP 39 CO/CI 6.9/3.22 K 3.4 THIS AM AND REPLEATED WITH 60 IV AND REPEAT LABS PENDING. RESP: 4L NP CRACKLES 1/2 UP BILATERALLY SATS MID 90'S. GI: POOR APETITE,NUTRITION CONSULT OBTAINED. Requesting [**Doctor Last Name 9**] beer NO STOOL. GU: URINE CONTAINS A LOT OF SEDIMENT.GOOD RESPONSE TO LASIX. HEME: INR 2.5 THIS AM. HCT 29.7 STABLE,REPEAT SENT THIS EVENING. ID: AFEBRILE SOCIAL: HUSBAND IN VISITING ||||END_OF_RECORD START_OF_RECORD=1||||16|||| npn 7p-7a: ccu nsg progress note: neuro--a&ox3, sleeping throughout the noc after getting trazadone/ativan, easily arrousable when needed, mae, skin w&d resp--ls cont w/crackles at bases, cta in upper lobes, conts on 4l nc w/sats 95-99%, rr 12-18, not labored, appears in nad cardiac--hr av paced at 70's, occ pvc noted, conts on dopa,initially on 5mcg w/maps 55-58, dopa increased to 6mcg w/increase in maps to 60, prior to getting captopril dose rate increased up to 7mcg w/maps up to 65-70, dopa weaned back down to 5mcg this am w/maps 60, pa numbers 58-65/30, cvp 26-30, unable to wedge, am co/ci---5.6/2.62, svr 564---this was drawn while on 6mcg of dopa, repeat hct from eve 27, team aware, no orders for transfusion at this time, will follow am hct, dr [**Last Name (STitle) 3**] in to talk w/pt this eve about condition and her need for ?heart transplant gi--abd firm/distended, (+)bs, still feels as though she has to have bm but conts to just pass gas, tol po's w/out diff gu--foley to gravity, draining orange urine, no clots noted, sediment present, given lasix 80mg at 6:45pm w/gd diuresis, cont'd w/gd u/o through noc of aprox 60-70cc/hr ||||END_OF_RECORD START_OF_RECORD=1||||17|||| CCU NPN: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA. CARDIAC: TITRATED DOPA NOW TO 4MCG/KG/MIN WITH MAP'S GREATER THAN 60. SWAN D/CED AND TRIPLE LUMEN PLACED THROUGH CORDIS AND MONITORING CVP. CAPTOPRIL INCREASED TO 12.5 MG TID. VOLUME:LASIX NOW BEING ORDERED AS 80MG BID WITH GREAT DIURESES TODAY,CURRENTLY NEG BY 1800CC. WT ALSO DOWN TO 88.6. HEME: HCT STABLE,INR 2.4 NO PLANS FOR HEPARIN AT THIS TIME. STOOL IS GUIAC POSITIVE GI:APPETITE HAS IMPROVED SLIGHTLY. NOW DRINKING SHAKES. HAS HAD TWO STOOLS SECOND MORE FORMED THAN FIRST.STILL HAS THE SENSATION OFTEN OF HAVING TO MOVE BOWELS,MOSTLY JUST FLATUS. ASCITES REMAINS GU: GREAT RESPONSE TO LASIX. URINE CONT TO HAVE SEDIMENT. LYTES: K REPLETED WITH 80 MEQ KCL,MAG REPLTED WITH 1 GM AND PHOS BEING REPLETED WITH NEUTROPHOS TID. SKIN: SKIN TEARS ON LEFT ARM CLEANSED AND LEFT OPEN TO AIR. BUTTOCKS IS RED AND STARTED ON DESTIN. PLAN: DR [**Last Name (STitle) 10**] IN TO TALK WITH PT REGARDING TRANSPLANT THIS EVENING. ||||END_OF_RECORD START_OF_RECORD=1||||18|||| npn 7p-7a: ccu nsg progress note: s: "i guess i have to make the decision about the transplant" o: cardiologist in speaking w/pt re:heart transplant which pt states she has to talk to her family about and make a decision. pt wants family to be able to talk to md's about transplant. pt a&ox3, given trazadone/ativan for sleep. did sleep through the noc, occ waking up. ls w/crackles at bases, no c/o sob, 4l on sat 97-98%, rr 18-20. conts on dopa initially on 4mcg but maps <60 when pt asleep, dopa increased to 6mcg then 7mcg w/maps >60. able to tol captopril 12.5mg. dopa again being weaned, at this time to 6mcg. abd firm/distended, (+)bs, lg soft, g(+)stool, (+)flatus. foley to gravity, draining lg amt of orange urine w/sediment, conts to c/o pain at cath, urine foul smelling, spec sent for ua/c&s. a: heart failure p: cont dopa, wean as tol monitor/asses cardiac status f/u w/cardiology re: heart transplant---have them meet w/family to up date them on status ||||END_OF_RECORD START_OF_RECORD=1||||19|||| s: i feel good today o: pls see carevue flowsheet for complete vs/data/events id: afeb. ua+. started on cipro. cv: hr 70s av paced. k and mg repleted. bp 90-105/50-60 via rad aline. dopa weaned to off. pt tol captopril at 12.5mg tid. hct cont at 27-28. no plans to transfuse unless<25. resp: cxs at bases up [**Date range (1) 11**]. sat 94% on 2lnc. no sob. gi: tol diet. no n/v. had sev loose stools. ob neg, brown. gu: good repsonse to lasix. aldactone added. foley changed. ms: ox3. cooperative. oob to ch for most of day. transfered with 1-2 assist. social: husband and dtr visited. dr [**Last Name (STitle) 3**] took husband and son's ph #s and planned to speak w/ then this afternoon. a: off dopa p: follow bp, i/o. act as tol. PT to see pt in am. support to pt and family. ||||END_OF_RECORD START_OF_RECORD=1||||20|||| npn 7p-7a: ccu nsg progress note: s:"i want to sit in the chair" o: pt in good spirits this eve, a&ox3, mae, skin w&d, oob to chair w/1 assist, steady gait, given trazadone/ativan for sleep, slept throughout the noc. no c/o sob, attempted to take o2 off w/sat to 88-89% although no c/o sob, 2l on w/sat up to 97%, ls w/crackles at bilat bases, cont on bid lasix. briefly talked about heart transplant stating that she didn't think that she wanted to have it done but that she would have to talk to her family about it more. no c/o cp, hr conts av paced at 70's, no ectopy, conts off dopamine w/maps 60-70, maps did drop to 50's for approx 1hr after getting captopril but came back up on own w/out any dopa. pt has tlcl that was placed over cordis which will have to be changed to just tlcl if pt goes to floor today. abd conts distended, soft, (+)bs, sm stool. foley initially leaking after given lasix, balloon inflated more and no further leaking. conts on cipro for uti, did c/o pain at urethra which resloved after lido jelly placed there. per pt dr [**Last Name (STitle) 3**] has husband/sons phone #s to call and update them on talk about heart transplant a: alt co d/t heart failure p: monitor/asses cardiac status--cont captopril, keep off dopa follow resp status, attempt to wean o2 as tol, ?cont to diuresis follow labs, replete lytes as indicated, follow hct, ? transfuse ||||END_OF_RECORD START_OF_RECORD=1||||21|||| S: "When is this bladder pain going to stop? this is worse than the swan" O: For complete VS see CCU flow sheet. ID: Pt afebrile. Urine + for UTI. She remains on cipro. CV: Pt has maintained stable BP off dopamine. HR 70s A-V paced. BP has ranged 88-130/50-60s. BP lower after captopril. She was replaced with 80 meq KCL today. She was restarted in heparin at 10am with ss written on low end. PTT was 63.4 and heparin was decreased from 900 to 700u/hr. PTT due 11pm. RESP: RR in 20s. She continues to have BB rales. On 2L 02 sats are 97-98%. She c/o of some nasal discomfort and with nasal prongs off she is sating 91-04%. She has no c/o of sob. GU: Pt c/o of bladder spasm. When she has spasm she feels as if she needs to move her bowels. She will be started on ditropan tonight. On commode she does leak urine into bedpan. She received standing lasix 100mg IV dose and diuresed well. She is now >1 liter neg for the day. HEME: Crit at 4p was stable at 28.2. GI: Pt onto commode ~14 times. She put out small amt soft G+ brown stool. She has poor apetite, but is taking nutritious shakes. ENDO: Finger sticks have not required ss reg coverage. ACTIVITY: Pt seen by PT today and walked. She has been very active, up to commode and back to chair frequently. She seems unsure of what the goal of this admission is and will need support with poor prognosis. Family in to visit and supportive. A: Restarted on heparin/bladder spasm P: Start ditropan. Support pt. Keep careful I & O. Continue PT. ||||END_OF_RECORD START_OF_RECORD=1||||22|||| NSG NOTE: CARDIAC: REMAINS OFF DOPAMINE WITH STABLE BP. AVPACED @ RATE 71. NO VEA NOTED. CAPTOPRIL DOSE INCREASED FROM 12.5 TO 25 MG,GIVEN AT MN. BP DROP 1/2 AFTER RECEIVING DOSE TO 75/40,88/46. HOUSE STAFF [**First Name8 (NamePattern2) 12**] [**Last Name (NamePattern1) 13**] AWARE. U/O DROP OFF SLIGHTLY,PT MENTATING,DENIES C/O AT THIS TIME. BP BACK UP AFTER OBSERVING FOR 1 HR,WITHOUT INTERVENTION TO MAP'S > 60. U/O IMPROVED GREATLY > 100CC/HR. CON'T TO RECEIVING IV HEPARIN. MD'S PREFER TO HAVE PT ON MORE OF SUBTHERAPEUTIC LEVEL (SEE PROTOCOL). PTT OVERNOC 61.4. RATE DECREASED FROM 700U TO 500U. CVP 24-26. RESP: O2 AT 2L NP WITH SATS 96%. DENIES SOB EVEN WITH EXERTION. HAS RALES 1/3 UP BILAT. RR-REG. ID: AFEBRILE. REMAINS ON CIPRO FOR UTI. GU: CON'T TO HAVE PERIODS OF BLADDER SPASMS. PT STARTED ON DITROPAN WITH SOME IMPROVEMENT. HAD HEMATURIA ON EVE SHIFT ? RELATED TO HEPARIN ADM. HEPARIN DOWN TO 500U/HR WITH IMPROVMENT IN HEMATURIA. RECEIVED 2 DOSES LASIX 80MG AND 40MG WITH GOOD RESPONCE. GI: HAD 2 SM BROWN SOFT STOOLS. CON'T TO C/O HEMMOROIDS PAIN. TUCKS ORDERED AND APPLIED WITH GOOD RELIEF. TOL DIET. DENIES N/V. ABD UNCHG. NEURO: A&O PLEASANT,COMPLIENT. COMFORT: C/O GENERALIZED ACHES AND PAINS. RECEIVED 1 TAB TYLENOL #3 WITH GOOD EFFECT. SKIN: UNCHG. HAD HEMATOMA'S R SHOULDER AND ON ARMS R AND L. ACTIVITY: OOB UP TO CH. TOL WELL. SEEN AND EVALUATED BY PT. REQUIERS STRENGTH AND ENDURANCE TRAINING. CAN PIVOT WELL FROM CH TO COMMODE WITH ASSIST OF 1. LABS: K+ 4.8 BS 125 PTT 61.4 DISPOSITION: TEAM HAS BEGUN TRANSPLANT DISCUSSION WITH PT AND FAMILY. PT DOES" NOT WANT TO FACE THAT" AND WANTS TO DELAY HER DECISION. A: STABLE ON INCREASING DOSE CAPTOPRIL. P: [**Hospital 14**] REHAB/PT TEAM TO CON'T TRANSPLANT DISCUSSION. CAPTOPRIL/CON'T DIURESIS. FOLLOW HCT NOW THAT PT IS ON HEPARIN AM LABS/PTT P: ||||END_OF_RECORD START_OF_RECORD=1||||23|||| S-"There is no way I am having a heart transplant, I need to go home and think about it-go on the internet..." O-Neuro alert and oriented x3, very pleasant and talkative today. Asked for a ativan in the afternoon for "nerves". CV-VSS no orthostatic VS changes when OOB commode/chair. Tolerating captopril 25mg TID despite SBP dipping to 80 after doses. Asymptomatic. Heparin at 500u/hr PTT 46. Off for 2 hours for RIJ line d/c'd and restarted at 1645. Last CVP 23. Resp- LS rales 1/3 up bilaterally. O2 off most of the day with O2 sats 90-93%. Encouraged to use IS and take deep breathe. ID afebrile 98.8po on cipro GU-foley draining amber urine no clots but occ blood tinged. C/o intermittant bladder spasm relieved with ditpropan. Received lasix 80mg IV BID with additional 40mg IVB at 2pm with good results. K 3.4 received additional 40meq po along with 40meq BID. GI-freq small soft BM OB- on the commode. Received immodium x1. Appetite improved. Needs to be limited po liquid intake otherwise would take in >2000cc. HCt remains low 26.4 recheck 26.8 at 3pm. SKin-occiput sutures removed by HO. Activity-OOB commode and chair [**Last Name (un) 15**] toelrated well. A few times pt up to the commode on her own. Wanting to take a walk. A/P-Improved VS on captopril/lasix ?change lasix to po dosing with prn IVB. Increase KCL po dose. FOllow HCT on Heparin. INcrease activity as tol. ||||END_OF_RECORD START_OF_RECORD=1||||24|||| CCU NURSING PROGRESS NOTE 7P-7A S-"JESUS I DON'T WANT TO LAY IN THE BED. I WANT TO SLEEP IN THE OTTOMAN CHAIR TONIGHT." NEURO: ALERT, ORIENTED X3, COOPERATIVE AND PLEASANT. CV: HR 70'S AV PACED. NO VEA NOTED. BP 90-110'S/50'S. BP DROPPED TO 80/40 AFTER CAPTOPRIL. PT DENIED C/O DIZZINESS. RECEIVED STANDING LASIX AND KCL DOSE AS ORDERED. BILAT LE EDEMA. CON'T ON HEPARIN AT 500 UNITS/HR. AM PTT PENDING. PULM: LS CLEAR, RIGHT BASE CRACKLES. O2 SATS 95-97% R/A. PT DENIES SOB. ENCOURAGED TO DEEP BREATHE. GI/GU: ABD ASCITES. +BS. FREQ SM BM'S OVERNIGHT ON COMMODE. FOLEY DRAINING CLEAR URINE, OCC BLOOD TINGED. PT C/O BLADDER SPASMS, SOME RELIEF WITH DITROPAN. ASKING TO HAVE FOLEY REMOVED. ENCOURAGED PT TO KEEP FOLEY IN OVERNIGHT. U/O APPROX 50-100 CC/HR (EXCEPT FOR SHORT TIME FOLLOWING CAPTOPRIL AND LOW BP, HO AWARE). ID: AFEBRILE. CON'T PO CIPRO. ACT: REMAINED IN CHAIR OVERNIGHT FOR PT COMFORT. PT STATES MUCH MORE COMFORTABLE IN CHAIR. UP TO COMMODE WITH MINIMAL ASSIST. COMFORT: GIVEN TYLENOL #3 X2 FOR C/O HEADACHE. SKIN: OCCIPUT INTACT AT LACERATION SITE. BRUISING ON RIGHT ARM AND SHOULDER. ACCESS: PERIPHERAL IV X1 PLAN: HEMODYNAMICALLY STABLE. INCREASE ACTIVITY AS TOLERATED. PT HAS BEEN CALLED OUT TO FLOOR. TRANSFER TO FLOOR WHEN BED AVAILABLE. ||||END_OF_RECORD START_OF_RECORD=1||||25|||| S-"I would like to go home tomorrow." O-Neuro alert and oriented x3, pleasant and cooperative anxious to go home Monday. Initial plan for milrinone x3 days. CV-VSS remains on milrinone at .288mcg/kg with symptomatic improvement of fatigue and SOB. SBP 83-105/60 Resp- LS clear without O2 no SOB noted with activity ID afebrile GU-voiding qs remains negative since MN GI appetite good , ate [**Last Name (un) 16**] sandwich Activity-OOB in room ad lib and walked in hallway ~200yards tolerated well without SOB A/P-stable day called out to floor with [**Last Name (un) 17**] dose of milrinone. ||||END_OF_RECORD START_OF_RECORD=1||||26|||| S-"I have more energy after walking. Dr. [**Last Name (STitle) 18**] is driving me crazy" O-Neuro alert and oriented x3, pleasant and cooperative. Feels better today. CV-Remains on IV heparin at 700u/hr PTT pnd. SBP dipping to 70's after captopril asymptomatic. Changed over to zestril 10mg po QD first dose at 1600. Also increased aldactone to 50mg QD. Resp-BBR O2 off sats 93% no cough ID afebrile GU-foley draining qs occ leakage esp after IV lasix. GI- appetite good, freq small soft BM's OB- HCT stable Activity-OOB with walker and assist. Walked approx 20 feet and had to sit down for 3 minutes and then walked another 20 feet back to the room. Tolerated well amd felt really good after. A/P-stable tolerating increase activity with meds adjustment. ||||END_OF_RECORD START_OF_RECORD=1||||27|||| CCU NURSING TRANSFER ACCEPT NOTE 58 YO FEMALE READMITTED TO CCU TODAY S/P CATH WITH PA LINE ON MILRINONE. PT WITH PMH MI '[**94**], CABG X3 '[**94**], REDO '[**97**], DDD PACER '[**97**], AFLUTTER S/P ABLATION '[**98**], AFIB S/P CARDIOVERSION, ECHO EF <20%, DM, PVD, DEPRESSION, CHF, HTN, AND ^CHOL. PT HAD ATTEMPT AT CATH FOR MILRINONE TRIAL, UNABLE TO PASS CATHETER R/T PVD. HAD RIGHT GROIN PA LINE PLACED. STARTED ON MILRINONE AND ADMITTED TO CCU FOR CLOSE MONITORING. NEURO: PT ALERT, ORIENTED X3, COOPERATIVE. MOVES ALL EXTREMETIES. CV: HR 71 AVP. BP 72-80/30'S. MILRINONE AT .35MCG/KG.MIN. LASIX STARTED AND INCREASED TO 4 MG/HR. PAP'S 60/23 MEAN 34-36. CVP 15-18. PCWP IN CATH LAB 30. MIXED VENOUS SAT 67 THIS AFTERNOON. CO 6.8 CI 3.18. PER MD'S PT TO BE STARTED ON NIPRIDE, MD'S AWARE SBP 70-80!!!! DOPPLER PT/DP. PULM: LS BIBAS. CRACKLES. SATS 92% R/A. 98% 2LNC. DENIES SOB. GI/GU: ABD DISTENDED, +BS X4. TOLERATING LIQUIDS WELL. FOLEY DRAINING CLEAR YELLOW URINE, TITRATING LASIX TO >100CC/HR. ACCESS: RIGHT GROIN PA LINE. RIGHT GROIN FEMORAL SHEATH DC'D BY FELLOW THIS AFTERNOON. NO BLEEDING/HEMATOMA NOTED. PIV X1 COMFORT: C/O BACK PAIN AND BILAT LEG PAIN. GIVEN PERCOCET AND REPOSITIONED WITH EFFECT. SOCIAL: HUSBAND IN TO VISIT THIS AFTERNOON. PLAN: CON'T MONITOR PA PRESSURES. ON MILRNONE. TITRATE LASIX TO DESIRED EFFECT. NIPRIDE FOR AFTERLOAD REDUCTION IF PT TOLERATES. RESUME HEPARIN. ||||END_OF_RECORD START_OF_RECORD=1||||28|||| S: "My left leg hurts. This has just been so long". O: For complete VS see CCU flow sheet. CV: Pt remains on milrinone at .35mic/kilo with sats staying at 67%m much improved from cath lab. C/O 5.6/67. Nipride was begun at low dose but BP did not tolerate. HR has been in 70s A-V paced and bp in low 80s. Heparin was begun at 7pm with PTT due at 1am. L groin remains dry wit no ooze or hematoma. RESP: O2 sat 98% on 2L NP. Lungs sound clear. RENAL: Despite increasing doses of lasix u/o has been low ~10-40cc/hr. Drip is presently on 20mg/hr. GI: Pt has poor apetite and took only liquids tonight.Her abdomen is very large. HEME: Dr [**Last Name (STitle) 19**] wants pt to have 2u PRBCs tonight. As she may be heart transplant candidate she needs irradiated, leukocyte poor RBCs. MS: Pt tearful and uncomfortable. She received 2 percocettes with fair results. Frequent position changes help. A: Improved c/o on milrinone P: Continue monitoring for change. Tranfuse 2 u PRBCs when ready. Increase lasix as needed. ||||END_OF_RECORD START_OF_RECORD=1||||29|||| S-"I am so uncomfortable I need to get OOB" O-Neuro alert and oriented x3, found very uncomfortable and sobbing at midnight. c/o back ache and right leg cramping from not being able to move it around. Treatedw ith tylenol #3 x2 and ativan 1mg po with good relief and slept well the rest of the night. CV-Milrinone at .375mcg/kg/min, hypotensive SBP 65 with MAP 35-45 HO notifed and milrinone decreased to .25mcg/kg/min and added dopamine 10mcg/kg to get SBP>90/MAP >60. Hemodynamics PA 54/18-70/21 after blood. Heparin at 1250u/hr PTT 99.8/INR 1.7/PT 16.0 Right fem sheath/PA cath no bleeding at site Resp-LS BBR O2 2l NP 90-95% ID afebrile GU-foley draining minimal amounts of urine despite lasix gtt at 20mg/hr. d/c'd gtt at 1:30am. With hypotension hourly urine 0-10cc/hr. BUN/CR 49/2.0 GI +ascites abd firm with hypoactive BS. Repeat HCT 29 last eve. Received 1 unit PRBC over 5 hours tolerated well. HCT pnd 7:30am. Mouth dry. Taking sips of water. Skin-very dry/red A/P-hypotension on milrinone. Oliguria with hypotension. ||||END_OF_RECORD START_OF_RECORD=1||||30|||| CCU NURSING PROGRESS NOTE 7A-7P NEURO: PT LETHARGIC BUT AROUSABLE. WAS AWAKE AND VERY ANXIOUS WHILE MD'S WORKING WITH HER, GIVEN TYLENOL #3 FOR BACK DISCOMFORT AND ATIVAN FOR ANXIETY. PT AROUSABLE TO VERBAL STIMULI, FOLLOWING COMMANDS APPRPOPRIATELY. CV: HR 70 AV PACED. BP 86-110/20-50'S. MILRINONE DC'D THIS AM R/T HYPOTENSION. DOPAMINE INCREASED TO KEEP MAPS >60, NOW UP TO 14 MCG/KG/MIN. SVO2 INITIALLY 60 OFF MILRINONE WITH CO 5.5 CI 3.09. HAS SINCE ^63 WITH ^U/O. PAP'S 68-78/17-29. CVP 17-25. UNABLE TO WEDGE GROIN PA LINE. HO AWARE. IV HEPARIN ADJUSTED PER PTT SS, NOW AT 700 UNITS/HR. HCT 26.9 S/P 1 UNIT RBC'S LAST NIGHT. RECEIVING 2ND UNIT RBC'S THIS AFTERNOON. DIG LEVEL 2.2 TODAY, RECHECK IN AM AND HOLD DIG TOMORROW. CORTISOL STIM TEST PERFORMED TODAY, RESULTS PENDING. PULM: LS CLEAR, BIBASILAR CRACKLES. O2 SAT 92-96% ON 2LNC. SATS LOW 90'S WHEN SLEEPING. GI/GU: ABD DISTENED, HYPOACTIVE BS. POOR PO INTAKE TODAY, SIPS WATER ONLY. FOLEY INITIALLY WITH POOR U/O. HAS SINCE INCREASED ONCE MILRINONE DC'D AND DOPA INCREASED. URINE IS NOW BLOOD TINGED, PT NOTED TO WINCE IN PAIN WHEN CATHETER MANIPULATED. HO MADE AWARE. NO INTERVENTION AT THIS TIME. BUN 52 CRT 2.1 ID: TEMP SPIKE 101.0 PAN CULTURED (BLOOD CULTURES X2 VIA LINES, UA AND URINE CULTURE) CXR DONE. GIVEN TYLENOL. SPOKE WITH MD'S, REPORTED TO GIVE RBC'S WITH TEMP. PLAN: MONITOR PAP'S AND BP, TITRATE DOPA TO MAINTAIN MAPS >60. ? WILL START DOBUTAMINE THIS EVENING TO ^CO. START ABX FOR TEMP SPIKE TODAY. OBSERVE FOR DECREASED U/O AND SIGNS/SYMPTOMS POOR PERFUSION. ||||END_OF_RECORD START_OF_RECORD=1||||31|||| S-"I'm just so uncomfortable" O-Neuro alert and oriented x3, c/o back ache received tylenol #3 x2 and ativan 1mg po for sleep. Slept most of night. CV-At 2130 restarted milrinone at .35mcg/kg after 50mcg/kg IVB over 10 minutes. Initial drop in SBP 83 but stable >90 most of night. Unable to wean dopamine much, 14mcg/kg to 11.4mcg/kg. Goal keep SBP >90. PAD 18-24 with CO/CI/SVR 9.9/5.56/356 after start of milrinone last eve. Recheck this am still pnd. Heparin at 700u/hr PTT 67. Resp- rr 16-24 O2 sats 90-95% LS BBR ID febrile 101.8R tylenol x1 98.8po this am. Started on abx. GU-foley draining 50-100cc/hr before milrinone. Started lasix gtt at 2mg/hr after 120mcg IVB and has had an excellant diuresis 150-300cc/hr. K 4.0 Imtermittant hematuria. GI-Appetite fair taking po liquids well. HCT 28 after 2nd unit of PRBC. Type and cross for 2u PRBC. NO BM's h/o melana on heparin in the past. Skin-dry using ucerin cream with some improvement. Open incision from old CABG last year LUL wet-dry dressing area is much improved with + granulation. A/P-Follow hemodynamics closely q 8hrs. Keep SBP >90 Follow electrolytes with diuresis h/o losing K+. ?restart zaroxylyn and aldactone. ||||END_OF_RECORD START_OF_RECORD=1||||32|||| Nursing Progress Note 7a-7p: Neuro: Pt alert and oriented x3. Pt stated that she thought she was going home today. Notified team that pt not understanding severity of illness. Moving all extremites spontaneously. CV: AV paved HR 71-73 no ectopy. Weaned dopamine gtt to 4mcg. SBP 97-130. Pt denies CP. PAD's 20-32. C.O. 7.8 CI 4.38 SVR 903. CVP 12. Hep gtt conts at 700u/hr PTT 62.0 no change per hep ss protocol. Milrinone gtt conts at 0.350mg/kg. K+ and mg repleted per prn order. HCT 28.4 per team transfuse <27.0. Heart Failure team to evaluate patient for transplant. Pt awaiting meeting with her husband present. PULM: NC 2.0 Sats 95%. Pt denies SOB. LS with bibasilary crackles. No peripheral edema noted. GI: Abd with +ascites. Hypoactive BS. Pt with abd discomfort rec'd tylenol 650mg po with effect. Pt with improved appetite, pt ate cottage ch and fruit plate. Pt taking sips of gingerale and water. No stool this shift. Pt asking for the bed pans many times w/o results. GU: Foley cath patent draining amber urine pt is on ditropan. u/o>70cc/hr until 4pm. 4-6p decreased to 10cc/hr with stable BP, H.O. notified. Conts on lasix gtt at 2mg/hr await further orders. ID: t max 99.3 po. Pt conts on abx. SKIN: LUE CABG site clean edges with red center. wet to dry dsg apiled. Heels pink, elevated off bed intermittently. Buttocks pink, turned prn. PAIN: Intermittent c/o back pain. Pt turned and given tylenol with effect. LINES: R groin PA line. R radial a-line. PROPH: hep gtt. DISPO: Full code SOCIAL: Family visiting throughout the day. A: Low grade temp with improving SVR on low dose dopamine and milrinone. P: Follow hemodynamics. Check PTT in am. Await lasix order for low u/o. follow temp curve. cont abx. replete electrolytes prn. Provide support. ||||END_OF_RECORD START_OF_RECORD=1||||33|||| S-" I'm in the church in [**Location 20**]" O-Neuro alert and oriented x1-2. Startedpicking at O2 and tape on arms and attempted to pull at foley catheter. Reoriented quickly but still continued to pick. Had received ativan 1mg and tyelnol #3 x2 as usual at bedtime. Finally fell asleep by 1:30AM. Desats to 88% on RA. CV-Hypotensive SBP 73 on dopamine 4mcg/kg increased back to 8mcg/kg with good response. BP 85-106/42-65. Hemodynamics PAP 53-61/20-24 CVP 15-18 with CO/CI/SVR 9.3/5.22/353. Heparin at 700u/hr PTT pnd 5am. Resp-LS BBR O2 2l np with O2 sats 90-95% but quickly desats to 85-88% off O2. ID afebrile on abx GU-Foley draining 10cc/hr and received lasix 120mg IVB and increased lasix gtt to 3-4mg/hr with good response ~1000cc. Received KCL 40meqIV GI-+BS taking po liquids well. Mouth dry Skin- open incision on upper left thigh closing up nicely with wet-dry dressing changes. Social- no call from family during the night. A/P-possibly change femoral PA catheter to neck? Freq orientation check. Have PT see pt while in bed to prevent deconditioning. ||||END_OF_RECORD START_OF_RECORD=1||||34|||| Nursing Progress Note 7a-7p: Neuro: Pt withdrawn and lethargic today. Pt dozing most of morning. Pt conts on zoloft and trazadone for depresssion. Pt requires frequent reminding of current situation. Pt conts ask if she is leaving today or tomorrow. Pt asks if she can get OOB and go to the bathroom following explaination of lines and meds. Team aware. Await Psych consult confirmation from Dr. [**Last Name (STitle) 19**]. Await PT eval. CV: AV paced 71-73. Pt denies CP. SBP 92-109 on dopamine gtt at 8mcg/kg/min. Do not wean Dopamine gtt per Dr. [**Last Name (STitle) 19**]. Milrinone gtt at 0.35mcg/kg/min. R groin PA line resited to RIJ this evening due to temp spike w/o source 48hrs ago and decrease mobility due to line.....AWAIT CXR for placement verification. R groin venous sheath pulled...monitor site. Pt tolerated procedure well after receiving 1mg po ativan. BP dropped transiently to SBP 80's. *PAD's 22-35. CVP 19. C.O./C.I./SVR 9.8/5.51/327. *Hep gtt off please turn on w/o bolus at 8pm per Resident. K+ 4.2 HCT 28.5 Transfusing <28.0. *Dig level 1.70 dig po conts to be on hold. Pt conts on lasix gtt at 4mg/hr with u/o 100cc/hr a/o. Wt 68.3kg(68.7). -1074 since mn -5872 LOS. Plan is to cont diuresis. Aldactone 25mg po restarted. PULM: NC 2.0 Sats 95-96%. Pt denies SOB. Pt able to lay flat. LS with crackles bibasilary. trace peripheral edema. GI: Abd soft distended with ascites. Pt refused meals. Denies n/v. Fruit plate in frig for pt. No stool tihs shift. ?LBM. Pt taking sips of water/tea. Oral mucosa is dry. ID: t max 99.4 Pt conts on abx iv. BC pending. SKIN: heels and buttocks red. Cream and repositoned. LUE old CABG site w-dry dsg. PROPH: Hep gtt. DISPO: Full Code SOCIAL: husband in to visit. A: afebrile with low SVR on milrinone and lasix gtt. P: Await CXR for swan placement. Re-start hep gtt at 8pm. Follow numbers with diuresis. Encourage po's. Follow mental status. Provide support. ||||END_OF_RECORD START_OF_RECORD=1||||35|||| S- " I WANT TO GO HOME- I WANT TO GET THESE THINGS OUT OF ME... I NEED TO CALL MY HUSBAND....I DON'T WANT TO HAVE THEM TAKE ME AWAY IN THE MIDDLE OF THE NIGHT AND PUT IN A (NEW) HEART....." O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAIN WITH BORDELINE LOW BP- 90/50- AS HIGH AS 110'S/ MILRINONE 0.35 MCG/HEPARIN 700U RESTARTED AT 8PM AFTER RT IJ PA LINE INSERTED. PAD- 24-32 WITH PCW- 18-26. CO/CI/SVR- 7.1/3.99/451 RESP- CX AT BASE BILATERALLY- 02 SATS WNL ON 2-4L NP- DROPPING TO HIGH 80'S OFF O2. REQURING FREQUENT REINFORCEMENT TO KEEP ON O2. REMAINS ON LASIX GTT 4 MG/HOUR. FAIR TO GOOD RESPONSE- 60-100CC/HOUR. SUCTIONING FOR MINIMAL PLUGGY THICK SECRETONS. I/O (-) 1400 AS OF 7AM. ID- AFEBRILE- CONTINUES ON ANTIBX- GU- GOOD UO- NO DIURESIS THIS SHIFT- (-) 1400/HOUR GI- NO PO INTAKE THIS SHIFT- ATTEMPTED BEDPAN X [**11-29**]. NO RESULTS. SOFT DISTENDED ABD. MS- TRAZADONE/ZOLOFT QHS- HELD OFF ATIVAN D/T INCREASED SOMNOLENCE UP TILL AROUND 11PM. REQUIRING REPEAT ORIENTATION AS TO PLACE, REASON FOR ADMISSION TO ICU ETC. BY 3 AM, APPEARING MORE LUCID, LESS CONFUSED. SPENT OVER 45 MINUTES ENCOURAGING PT - EXPLAINING COURSE OF CARE. ASKING TO GET OUT OF BED, AFRAID WE ARE DOING THINGS WITHOUT HER KNOWING IT, WILL SEND HER TO THE OR TO GET A NEW HEART WITHOUT HER PERMISSION, ETC. ASKING TO SPEAK TO HUSBAND, DR [**Last Name (STitle) **], DR [**Last Name (STitle) 21**]. ENCOURAGED TO WAIT UNTIL THE DAYTIME FOR SUCH CALLS. PT ESCALATING BY 5 AM AND WANTING TO GET OOB, GO FOR WALK, PULL OUT LINES ETC. CALLED PT'S HUSBAND, BUT NO ANSWER. MUCH MUCH ENCOURAGEMENT AND LIMIT SETTING. HOLDING OFF ON ATIVAN D/T APPARENT CONFUSION/SOMNOLENCE FROM DRUG. PT IS CONVINCED WE WANT TO HOLD HER PRISONER. A/P- PT WITH CHF/LOW EF STATE DOPA/MILRINONE DEPENDANT CURRENTLY HEMODYNAMICALLY STABLE WITH GOOD DIURESIS/ I/O. ALTERED COPING SKILLS CONTINUE TO CLOSELY MONITOR HEMODYNAMICS- MEETING WITH TEAM/ATTENDINGS TO DISCUSS OVERALL PLAN OF CARE WITH STAFF/PT/FAMILY. PT IS ADAMENT CURRENTLY TO GO HOME, NOT HAVE ANY HEART TRANSPLANT ETC. CONTINUE TO SUPPORT/SET LIMITS TO ENSURE PT SAFETY. ALLOW PT TO MAKE DECISIONS RE: OWN CARE AS LONG AS NOT ENDANGERING TO PT. CONTINUE TO DIURESE WITH LASIX GTT. PSYCH CONSULT TODAY TO EVALUATE ESP IN SETTING OF POSSIBLE TRANSPLANT W/U. LIMIT SETTING/CONTRACT. ||||END_OF_RECORD START_OF_RECORD=1||||36|||| ERROR: PT NOT SUCTIONED AT ALL AS MENTIONED IN RESP SECTION OF OBJECTIVE DATA. ||||END_OF_RECORD START_OF_RECORD=1||||37|||| S: "I think I feel a little better" O: For complete VS see CCU flow sheet. ID: PT remains afebrile today. CV: Per Dr. [**Last Name (STitle) 22**] pt has remained on the same meds today: dopamine 8 mic/kilo, milrinone .35 mic/kilo and heparin at 700u/hr. Her CO at 2pm was 6.1/ 3.43 with SVR 511. She was started on enalapril 2.5 at 5pm and has tolerated it without drop in BP. HR has been in 70s AV paced with no ectopy, and BP stable in 90s/30-40s with PS 50-60s/ 20-26 with RA 17. She was K+ replaced with repeat K+ 4.0 and received 2amp mgso4. Her digoxin .125 was restarted this am. RESP: Pt frequently takes off 02 and sat then drops to 88-93%. On 4L NP sats are 96-99%. She continues to have BBR. RENAL: Pt on insulin drip at 4mg most of the day. It was increased to 6u at 5pm and u/o has picked up. She is 200cc neg for the day. GI: Pt has very poor apetite. She did eat 2 eggs and is drinking nutricious frappes. She was up to the commode ~10 times today. After suppository she had large G+ stool. SKIN: Wet to dry dsg done to small open area on L thigh. Area appears to be healing and is clean. MS: Pt seen by psych today. They suggested increasing zoloft which has been done. Pt up in chair the whole day and has been more comfortable and appropriate. A: Stable c/o on stable presures P: Continue with above meds over the weekend. Support pt and family. Keep careful I & O. Check K+ and replace for less than 4.0 ||||END_OF_RECORD START_OF_RECORD=1||||38|||| No changes made to medical regime over this 4 hrs. Remains hemodynamically stable, is comfortable in the chair and would like to remain there, has been sleeping on and off. Up to commode x1, passed mucous and blood, sm amt. Given Mesalamine supp. Aloe Vesta oint applied to rectal area. UO good, is 400cc neg at 2200. A/P: cont close hemodynamic monitoring. ||||END_OF_RECORD START_OF_RECORD=1||||39|||| S:" I don't want to get in the bed, I'm more comfortable in the chair." O: Please see carevue for VS and objective data. CVS: Hemodynamically stable but Dopamine dependent with SBP trending down to the 70's when changing Dopamine bag. BP 70's-109/40-50's. IV Dopamine at 10mcg/kg/min. IV Milrinone at 0.35mcg/kg/min. CO/CI 6.3/3.54, unable to calculate SVR due to CVP port clotted. IV Heparin at 700u/hour with am PTT pnd. HR 60-70's 100% AV paced, no vea noted, K+ repletion as per flow. Resp: Po2 78 on 2l n/c, increased to 107 on 4 L n/c. Lungs with rales in bases only. IV Lasix titrated to maintain net u/o of 100cc/hour. Presently at 9mg/hour. GI;GU: Small sips taken with meds. Voiding qs as above via foley. OOB to commode x3 for very small amount of loose mucous, no stool. Neuro: Pt. A/A/Ox3, calm and cooperative this shift. Pt. states she is most comfortable in cardiac chair and requested to sleep in cardiac chair. Refused return to bed when encouraged. Slept on and off most of night. A: Stable, dependent on IV drips. P: Cont to assess hemodynamics, maintain drips as ordered. Titrate Lasix drip to maintain net u/o of 100cc neg. Follow up with am labs. Cont to assess mental status, safety measures. Comfort and emotional support to Pt. and family. ||||END_OF_RECORD START_OF_RECORD=1||||40|||| S: "I really do feel better today, though still no apetite." O: For complete VS see CCU flow sheet. ID: T-max 98.5 po. Flagyl d/c. CV: Pt continues on milrinone at .35 mic/kilo. HR has been in 70s av paced. BP has been stable in 90s to low 100s. By the afternoon dopamine was reduced to 8mic/kilo from 10mic/kilo with bp still in 90-low 100s. PAP has slowly been decreasing and is in 50-60/19-23s. Wedge was 18-19. Last c/o was lower at 5.5/ 3.09/ 611 on the 10 mic/kilo of dopamine. Her K+ today was 4.1. She continues on 700u heparin with stable PTT. RESP: Pt sating better with room air sats now 94-96% range and 98-100% on 4L NP. Lungs sound nearly clear with faint crackles at the bases. GU: Urine output has increased and she is now ~500cc neg for the day on 9mg lasix/hr. GI: Apetite very poor, despite attempts to get food that she likes. She is drinking the nutri-shakes though. No BM today. HEME: Crit 26 this am and she was transfused with unit of PRBCs this afternoon--completed at 6:30p. She had not problem with [**Name2 (NI) 23**]. SKIN: Dsg to small open area on L thigh changed. Looks clean. Salve applied to groin rash. MS: Pt stayed in chair for day. She will stand up ocassionally with minimal support, but tires easily and needs to sit. She requested and received 1mg po ativan this afternoon. She slept for a short time only after receiving it. A: Decreased dopamine. Decreased c/o. Increased u/o P: Continue to monitor hemodynamics. Decrease dopa as tolerated. Encourage po intake. ||||END_OF_RECORD START_OF_RECORD=1||||41|||| Neuro: Pt is A&O x3. Pt is frustrated with beigng in hosp. Pt able to move all extremeties well, Pt able to take small steps to camode, chair and bed. Cardiac: Pts rhythm is AV paced, HR in the 72, BP, pt is hypotensive. Attempt to keep SBP > 90. Pt has R IJ SWAN. PA pressures 60's-70's/20's, Wedge 16, CVP in high teens. Fick sent off in am. Pt on Dopa, initially on 8mcg, decreased to 7mcg, attempted to decrease to 6mcg, but pts BP decreased into the 80's. Pt on Milnerone at .35mcg, Pt on 700u/hr heparin; AM labs pending. Pt also has R rad al, and R IJ cordis. Resp: Pt is on 2L NC, decreased from 4L pt hving nose bleeds, and O2sat mid to high 90's on RA, therefore decreased O2, O2 sats on 2L are in high 90's. BS clear in upper lobes, and rales in lower lobes. Pt denies SOB. Question dx of pneumonia. GI: Pt has pos BS. ABD is greatly firm and distnded secondary to R heart failure. Pt has poor appetite, pt ate 2 packages of crackers last night, pt informed about fluid restriction, and importance of nutritional consumption. Pt up to camode x2. no BM GU: Pt on lasix drip at 9 mg/hr. Goal is to be -100cc q hr. Pt putting out adequate uring output. Skin: Pt has small breakdown on L upper thing, healing nicely, pt has wet to dry dsg, BID changed at 2100. Pt had protective lotion placed multiple times. Pt has much pain in rectup, pt given supposortory. Misc: Pt received 2mg MSO4 for severe R foot pain, med resolved pain. Pt slept for majority of night. No tmax. ||||END_OF_RECORD START_OF_RECORD=1||||42|||| S: "I definitely feel better" O: For complete VS see CCU flow sheet. ID: T-max 99.6po. Cont on ABX. CV: Pt remains on milrinone at .35mic/kilo. 2.5 enalapril given today and tolerated. Dopamine only decreased to 6.5mic/kilo with BP in low 90s/40s up to high 90s. HR stable in 70 av paced. K+ 3.7 in am and pt replaced with 40meq IV and repeat K+ was 4.1. PAP continue to decrease slightly, epecially right heart pressures: PAP 50/18-21, wedge 17, and RA [**09-11**]. Heparin continues at 700u/hr with just theraputic PTT. Pt overall feeling better. RESP: Pt now sating 95-98% on RA and 100% on 2L. Contd. rales up 1/4 on R and at bases on L. GU: Urine output excellent on 9mg lasix/hr. Pt 1400cc neg thus far today. GI: Pt continues to request commode ~ Q1 hour, despite not moving bowels. She did receive suppository and had very small hard stool. Apetite poor, though she will drink nutrashakes. SKIN: Rash on groin continues red and sore. Barrier cream applied frequently. Small wound on upper thigh appeared healed over this am and dry sterile dsg was applied. It should continue to be assessed to ensure it continue to heal appropriately. A: Stable on mirinone. Tolerated vasotec. Unable to wean dopa further P: Monitor I & O carefully. Increase lasix if necessary. Contue trying to wean dopamine. Comfort: Pt feeling stiff and achy. She received 1 tylenol #3. She spent day in chair. ||||END_OF_RECORD START_OF_RECORD=1||||43|||| Neuro: Pt is A&O x3 Pt, moves all extremeties well, pt OOB to cardiac chair and camode many times. Pt claims "I want to go home tomorrow." I spoke ot MD and he stated that he would talk to pt tomorrow. [**07-03**] Cardiac: Pt has cordis, swan, and R rad AL. Pt is AV paced at a rate of 71. Pts BP dopa dependant, Order written to maintain SBP of 80. Pts BP in 80's to 100's systolic, very low map. Pts PA pressures 50's/high teen's to low 20's. CVP 12-14, wedge 15-19. Pt on .35mcg Milrinone, currently on 6mcg of dopa, Order written to [**Last Name (un) 24**] dopa off and to maintain SBP of 80; dopa decreased to 4.5mcg from 6.5mcg, when urine output decreased to zero, despite lasix drip being increased to 12 from 9 mg/hr. When dopa increased to 6mcg urine output immediately increased. Pt kept on 12 mg of lasix to compensate for decreased urine output of 4-5 hours. Lasix may need to be decreased back to 9mg. Pt goal is -100cc/hr. Pt on 700u/hr heparin. AM labs pending, no CO or SVR avaliable to write in report. Resp: Pt on 2L O2 via NC. Pts O2 sat high 90's. BS clear in the upper lobes, rales in lower lobes bilaterally. Pt denies SOB. GI: Pt is on low salt and low cholester diet, however pt has no appetite. Abd is firm and distended secondary to ascites from R heart failure. No tap in near future. decreased BS. Pt is bowel obsessed, pt requests to go to camode multiple times a shift, unable to stool. 2 days ago pt given a supposotory and had large BM, since then pt has not eaten to produce stool. Pt con't to request and insist that she has to have a movement. Pt will drink neutri shakes, please encourage her to do so. GU: As explained above, pts goal of -100cc/hr, urine decreased to zero secondary to [**Last Name (un) 24**] of dopa, lasix increased to 12 mg from 9 mg without effect, dopa then increased again, immediately increasing urine output. Skin: Pt has small lesion on L thigh Wet to dry dsg, changed at 2300, appears to have signs of healing well. Pt has significant rash in peri area, barrier cream applied multiple times a shift. May need something stronger. ||||END_OF_RECORD START_OF_RECORD=1||||44|||| REMAINS STABLE w/ swan ganz catheter, off millrinone gtt, on dopamine gtt, heparin gtt, lasix gtt. ROS: CARDIAC: d/c'd millrinone w/ increased svr. Tolerating slow dopamine taper, decreased lasix gtt. Pain free. Swan remains in place. (see careview for data). Began vasotec, to monitor through night and repeat dose @ 6am, with numbers for rounds. Slow taper dopa if tolerates. Recheck ptt 11pm. She has very good activity tolerance w/ transfer to and from chair multiple times w/ only assistance required for management of lines. RESP: on room air w/ good sats. GI: taking good po intake...adequate nutrition. To commode, no stool. Distended abdomen r/t acites. GU/RENAL: excellent response to lasix gtt, requiring tapering gtt. Bun 30/cr 1.1 HEME: hct 26.7...for unit prbc tonight. ASSESS: stable, tolerating slow wean from dopa. PLAN: for unit prbc, recheck numbers this evening, monitor urine output, for PPD plant by intern ||||END_OF_RECORD START_OF_RECORD=1||||45|||| S- " I NEED TO GET OUT OF THIS CHAIR.." O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- VS REMAIN STABLE. HR- 70-'S AV PACED- NO VEA. BP- 88/42- 90/40- REMAINS OFF MILRINONE AND ON DOPA 5.5 MCG/KG. REPEAT CO/CI OFF MILRINONE- SIMILAR TO PREVIOUS- 5.3/2.98. UNABLE TO CALCULATE SVR B/C CVP PORT DAMPENED/UNABLE TO FLUSH. STARTED ENALAPRIL 2.5 MG BID. PAD- 20-24/ PCW- 20-22. HEPARIN GTT CONTINUES 800U- PTT- 60. OUT OF CHAIR TO COMMODE FREQUENTLY WITHOUT RESULTS. TOLERATING INCREASED ACTIVITY BUT REQUIRING MUCH ASSISTANCE WITH LINES. RESP- PT REMAINS ON ROOM AIR- O2 SATS MID 90'S. DIURESING WELL TO 8 MG/HOUR LASIX- I/O- -1400CC AS OF 12 AM. OVERALL (-) 15 LITERS FROM ADMISSION. GU- SEE ABOVE- UO- 75-120/HOUR. NO CHANGE WITH LASIX GTT DOSE. GI- ATTEMPTING COMMODE CHAIR- NO RESULTS. ID- AFEBRILE- HEME- HCT- 26.7 IN AM- SET UP AND TRANSFUSED WITH ONE U PRBC 12AM. MS- PT VERY ALERT AND AWAKE- OUT OF THE CHAIR TO COMMODE - NOT WANTING TO GET BACK TO BED UNTIL AROUND 2AM. CURRENTLY RESTING ON/OFF IN BED. A/P- PT S/P CV SHOCK/CHF CURRENTLY RESPONDING TO DIURESIS/MILRINONE TRIAL. CONTINUE LASIX/DOPA TO KEEP U.O > 100CC/HOUR. CONTINUE TO MAX RPP- ENALAPRIL AS ORDERED- CHECK CO/CI ON DOSE. CONSIDER REMOVING PA LINE TODAY TO ALLOW FOR INCREASED MOBILITY NOW THAT DIURESED WITH STABLE CO/CI MUCH SUPPORT. CONTINUE PRELIMINARY HEART TRANSPLANT W/U. ||||END_OF_RECORD START_OF_RECORD=1||||46|||| s: i haven't gone yet(bm) o: pls see carevue flowsheet for complete vs/data/events cv: hr 70s av paced. bp 82-98/45-50 via r rad aline. dopa weaned off this eve with drop in bp to 80s/ but well tol. co remains acceptable at 5.1/ci 2.87. (unable to do svr b/c cvp port in nonfunctional). enalapril at 2.5mg bid. pt rec'd an additional 2.5 this afternoon. pap: 50-60/23-25. heparin at 850u/hr. ptt 59.7. resp: basilar cxs. no sob. ra sat 94-98%. gu: foley to [**Last Name (un) 25**]. uop dropped from 100-120cc/hr to 40 then 10cc/hr as dopa was weaned , then dc'd. lasix gtt to be increased from 8 to 10mg/hr. currently 350cc neg from mn. gi: tol diet with fair intake. no n/v. feels she need to have a bm. on the commade at least once an hour without results despite mom x2. ms: a+ox3, cooperative. oob with min assist for lines, etc. visiting with friends this [**Name2 (NI) 26**], in good spirits. a: dopa off with fall in uop. p: follow co this eve. assess response to ^'d lasix gtt. ?need for more aggressive bowel meds. provide info and support to pt and family. ||||END_OF_RECORD START_OF_RECORD=1||||47|||| CCU NURSING PROGRESS NOTE 11p-7a NEURO: awake, a&ox3. Pt independently oob-> chair/commode. Tolerated well. RESP: LS clear. Sats 94-95% on room air. CARDIAC: BP 90's most of the shift. Will intermittently dip to mid 80's (of note, a-line is very positional). C.O. up to 9 and CI 5.06 this am. Remains off dopamine and milrinone. Tolerating po enalapril. Pt did receive additional dose of lasix preceded by 5mg po zaroxolyn with minimal results. Pt 176cc negative this am (however, noted pt voiding around foley cath-> therefore was dc'd this morning). GI: Tolerating cardiac diet. Taking good po's. Pt up to commode several times overnight with urge to void and stool, however only one lg black liquid stool mixed with urine. GU: foley with minimal urine output most of the shift, however as noted above, foley was leaking and appeared to be mostly out this am. Catheter has been dc'd. Pt instructed to save all urine in commode. ID: afebrile ||||END_OF_RECORD START_OF_RECORD=1||||48|||| ccu nursing progress note 7a-7p neuro: alert, oriented x3. pt becoming anxious at times through day. attempts made to calm pt with some success. cv: hr 70's av paced. bp 88-102/50-60's. pap's 48-56/24-28. svo2 66-69. most recent co 5.5 ci 3.09 off dopa and milrinone. tolerated enalapril 2.5 this am, dose remains same at present and given this evening. lasix changed to 90mg q 6hr, next dose to be given with zaroxolyn and then to zarox to be qam. heparin 850 units/hr turned off at 2:30 for paracentesis, to be restarted later this evening. pt to be seen by tranplant team in am, and to have tee at 11 am tomorrow. pulm: ls clear. sats 99% r/a. denies sob gi/gu: fair po intake. us guided paracentesis today removed 3700cc. pt voiding on commode approx 100cc/hr. access: pa line and right radial aline. plan: tee in am. cont transplant workup. to receive zarox and lasix this eve, then to start ? nitroglycerin iv. cont monitor pa pressures and diuresis. ||||END_OF_RECORD START_OF_RECORD=1||||49|||| npn 7p-7a ccu nsg progress note: s:"leave that side rail down" o: pt a&ox3, mae, skin w&d, color pale, does not have any c/o's throughout the noc, does get up to commode/chair several times during noc w/assistance. no c/o sob, no cp, ls cta, sats on ra 95-97%, rr 18-20, hr 70's av paced, bp 79-93/30-40, pa #'s 46-60/18-30, ntg gtt started at 2.5mcg, co/ci after being on ntg up to 6.6/3.71, am #'s pnd, hep gtt restarted at 11pm post paracentesis, am ptt pnd, conts to diuresis, given zaroxyln last pm prior to lasix, has been voiding w/out diff approx 100cc/hr, conts to tol enalapril 2.5mg w/out any change in bp, pt has been npo during noc for tee this am, also plan is for transplant team to see pt this am, abd soft, non tender to palpation, (+)bs, site where tap was done remains dry/intact, pt states that she does not change in abd since fluid removed a: chf/heart failure p: cont current treatment for heart failure f/u w/transplant team after eval today ?d/c swan or cont to monitor #'s cont diruesis ||||END_OF_RECORD START_OF_RECORD=1||||50|||| She remained stable ...stable v.s....stable filling pressures while awaiting TEE. Seen by Cardic Transplant surgeon. She initially agreed to the TEE, asking appropriate questions. She was npo after mn for TEE that never happened. She was irritated , speaking at length w/ the team regarding her wishes, concerns and direction regarding transplant vs. going home. primary MD to come today to consult w/ her and the team. Transfers independently bed to chair to commode etc. w/out difficulties. Good balance. No sob. On room air. Remains on tiny dose nitro. Heparin gtt. Taking po. Assess: stable. PlAN: per outcome of team discussion w/ primary. ||||END_OF_RECORD START_OF_RECORD=1||||51|||| S. "I JUST WANT TO GO HOME! - NO MORE TESTS!" O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: HR 70'S AV PACED, BP 70-87/30'S, RUNNING IN 70'S SYSTOLIC FOR SEVERAL HOURS AFTER RECEIVING ENALAPRIL 2.5MG AT 5:30 PM, ASSYMPTOMATIC, PA P'S 50'S/24-26 WHILE SITTING UPRIGHT, 69-76/36 WHEN LYING IN BED/RE-ZEROED, CO/CI AT 10P = 6.1/3.43 - UNABLE TO OBTAIN CVP - PORT CLOTTED OFF; RECEIVING LASIX QID - TOTAL 2.5 LITERS NEGATIVE TODAY; PTT ON HEPARIN 700U/HR = 42 - RECEIVED 1200U BOLUS AND INCREASED GTT TO 800U/HR AT 6 PM, PTT DUE AT MN RESP: SATS HIGH 90'S ON ROOM AIR, LUNGS CLEAR GI: TOLERATING CARDIAC DIET IN SMALL AMTS, NO STOOL GU: VOIDING WELL IN BEDPAN MS: A+O X 3, REQUESTED ATIVAN 1MG PO X 1, PT STATES SHE IS "HAVING A BAD DAY EMOTIONALLY" - "I'M READY TO GIVE UP - I DON'T WANT ANY MORE TESTS." "I DON'T WANT TO HAVE A TRANSPLANT!" - AFTER LONG DISCUSSION W/DR. [**Last Name (STitle) **]/RN, AGREED THAT GOALS OF CARE WILL BE TO FOCUS ON GETTING PT ON ORAL REGIMEN THAT SHE CAN GO HOME ON; PT TOLD THAT WOULD TAKE SEVERAL DAYS AT BEST; LATER IN EVENING PT CONTINUED TO NEED REINFORCEMENT THAT WE DID NOT WANT TO DO "MORE TESTS" ON HER AT THIS TIME AND THAT WE WILL NOT CONSIDER TRANSPLANT AT THIS TIME PER HER WISHES. SOCIAL: HUSBAND IN TO VISIT X 1HR THIS EVENING A: DROP IN BP AFTER ENALAPRIL 2.5MG - ASSYMPTOMATIC PAP'S REMAIN HIGH DESPITE CONTINUED DIURESIS EMOTIONALLY STRESSED W/LONG HOSPITALIZATION P: FOLLOW HEMODYNAMICS OVERNIGHT ON PRESENT MEDICAL REGIME ? D/C SWAN/A-LINE IF STABLE OVERNIGHT, PROVIDE EMOTIONAL SUPPORT, REINFORCE PLAN W/PATIENT, PRN. ||||END_OF_RECORD START_OF_RECORD=1||||52|||| O: SEE FLOW SHEET SECTION FOR CLINICAL INFORMATION: NEURO: ALERT, ORIENTED X 3; APPROPRIATE. PSYCHOSOCIAL: PLEASANT; AFFECT NOT DEPRESSED DURING NIGHT CV: AV PACED; BP RANGE REFLECTING VERY LOW DOSE IV NTG, PO VASOTEC, IV LASIX; PAD'S 24- 37 WHEN RESTING IN BED; PAD'S INVALID WHEN OOB TO CHAIR; ON IV HEPARIN AT 900 UNITS/HR PER PROTOCOL; RESP: O2 SAT 95,96 ON ROOM AIR. RENAL: OOB TO COMMODE- VOIDING QS POST LASIX. GI: TAKING SIPS OF CRANBERRY JUICE; MAINTAINING GOOD FLUID RESTRICTION; NO BOWEL MOVEMENT OVERNIGHT. ACTIVITY TOLERANCE: OOB TO CHAIR AND COMMODE- TOLERATED WELL WITHOUT FATIGUE OR SOB. A: NO ACUTE CARDIAC OR RESPIRATORY DECOMPENSATION THIS NIGHT; SPIRITS SOMEW HAT IMPROVED. P: AWAIT AM LABS, CO/CI; MAINTAIN IV NTG, IV HEPARIN; ATTEMPT AT INCREASING PO VASOTEC; FOR POSSIBLE TRANSFER TO PCU LATER THIS DAY. ||||END_OF_RECORD START_OF_RECORD=1||||53|||| 58 y.o. woman w/ cardiomyopathy admitted to hospital [**2000-05-30**]. (see past hx from admit note). Readmitted to CCu [**06-26**] from cath lab on milrinone gtt for PA monitoring while med management and evaluation for cardiac transplant. Swan and a-line out today, maximixed med management, for transfer to floor. CARDIAC: Pt not interested in cardiac transplant at this time. Being followed closely by Dr [**Last Name (STitle) 19**]. HR 72 AVP. B/P 78-80's SBP. Using mental status as guidline regarding med parameters, not b/p. pain free. On aggressive daily diuresis. Prn electrolyte replacements. On heparin gtt 900u/hr. RESP: room air w/ sats mid 90's. No sob. GI; taking po. ACTIVITY: needs asst w/ some bathing adl's, otherwise independent bed->chair->commode. tolerates well. PT following w/ exercises. WT [**07-05**] 59.2kg. peripheral lines #20x2 R arm. Aline d/c today w/ pressure dsg. R cordis and swan d/c today w/ dressing. SKIN: rash on back of legs ? etiology, has this skin, tearing easily w/ tape. Tape tears on R arm w/ tegraderm overlay. Neuro: intact, expressions of depression w/ several requests to go home. Followed by social service. SOCIAL; l/w husband who visits daily and involved in care. ASSESS; stable for transfer to cardiac floor PLAN; monitor volume status, electrolytes, discharge planning, check ptt 10pm tonight. ||||END_OF_RECORD START_OF_RECORD=1||||54|||| S: " I don't feel good " O: 58 yo female with severe CAD, EF 20% in hospital since [**05-31**] for treatment of progressive CHF, recently d/c'd from CCU after aggressive diuresis and inotropic support. Now re-admitted to CCU after progressive increase in creatinine and decrease in u/o. went to cath lab for right fem. swan showing RA 20, PA 80/30, W 35, MVO2 48%. PMH: CAD, CABG '[**94**], all grafts occluded. echo [**1990-04-27**] showing EF 20-25%, severe TR. baseline BP 70's -80's/ on floor. AV paced 70 creatinine up to 2.3(1.6) [**07-12**] with poor u/o despite >1liter fluid. foley placed on floor for only 30cc. decesion made to take to cath for swan. tolerated cath . opening pressures as above. started on dopa up to 10mcq with BP up to 90-110/. 60mg lasix IV -> 850cc responce. also started on nipride at .07mcq/kg/min. arrived to CCU at 2300 [**07-12**]. CCU: neuro: awake, cooperative. ativan 1mg po at 0200 for general anxiety with moderate effect. light sleeper. CV: HR 70-72 AV paced. BP on arrival 93/40. dopa at 10mcq, nipride .07mcq/kg/min and heparin 850u/hr. MVO2 72%, C.O. 7.1/4.1. u/o 350-400cc/hr with BP 94-99/30-40, therefore dopa decreased to 7.5mcq at 0145. BP down to 80-85/40 and u/o only 100cc in 1 hr. - dopa increased to 9.0mcq at 0315. heme: HCT 26.5 (7pm [**07-12**]) down from 28 in AM. tranfused one UPRBC 2400-0400. tol. well. resp: sats 96-97% on 4lnc. LS diminished bases. clear upper. denies SOB renal: plan renal U/S per resident. pt. had c/o right flank pain on floor. here, c/o general abd discomfort, some nausea which she states she has had before. also anxious, given ativan and able to sleep. skin: pink/red rash between legs, using myconizole cream. A: decompensated hear failure requiring ICU stay for inotropy and diuresis P: follow PAP's, u/o, lytes, HCT 2 hours after transfusion. titrate dopa for u/o 200cc/hr, nipride, heparin ||||END_OF_RECORD START_OF_RECORD=1||||55|||| n-quite somulent this am, flumazinal given-gradually more alert and appropriately interactive throughout the day, r-ra sats 98% breathing comfortably minimal biasilar crackles cv-av paced 70, Map's>60 on dopa at 8 mcg's, co/ci pa sats improved to 5-6/3-4/0-80 and has duireses 4liters since mn without lasix r fem pa line intact, iv hep at 850u/hr ptt 80 gi-poor po intake , primarily just po fluids gu-auto diuresing afebrile c/o sore back-slight red bottom-frequent re-position, 1 perc prn with fair response thus far a/p-improving heart failure with dopa, continue all current supports ||||END_OF_RECORD START_OF_RECORD=1||||56|||| O:CRYING @ X'S NOT SURE WHY-WITHDRAWN. SL CONFUSED-WONDERING WHEN SHE'S GOING TO GO BACK TO THE HOSPITAL. BRREATH SOUNDS-CLEAR. SATS UPPER 90'S. HEMODY STABLE. PAD'S LOW TEENS. DOPA & HEPARIN INFUSING AS ORDERED. EXCELLENT UO. AFEBRILE. AM LABS SENT. A:TIRED OF BEING IN HOSPITAL. RESPONDING TO DOPA GTT W EXCELLENT UO. P:?ATTEMPT TO GET PT HOME W ASSISTANCE. CONTIN DOPA GTT-MAINT ADEQ UO. ?DC PA/INTRODUCER-NEEDS CENTRAL ACCESS. SUPPORT AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=1||||57|||| n-weepy, states she doesn't want to die and doesn't want to be here, alert and appropriately interactive but depressed and has had enough of the constraints of icu monitoring r-bbsds, cta, rr teens breathing comfortably sats>98% cv-av paced 71, bp 90/37 pads teens, co/ci 4-6/2-4 pa sats 60-70 added back enalapril, weaned dopa to 5 but bp 80's and uo decreased therefore increased to 6 and bp just above 90 uo 50/cc hr- attempting to wean dopa to stable dose to allow adequate uo/bp, r fem pa line intact- attempted picc today unsuccessful-plan to do with IR on monday gi-poor po intake-no stool-bowel meds given gu-qsuo via foley approx 50 cc/hr at presetn dopa of 6, creat had returned to 1.1 will follow afebrile husband in and updated a/p-dopa dependent, needs new central access, follow hemodynamic parameters and fluid volume balance ||||END_OF_RECORD START_OF_RECORD=1||||58|||| NEURO: A&O X3. DEPRESSED D/T LENGTHY HOSPITALIZATION. TEARY DURING BEGINNING OF SHIFT. DID NOT WANT TO HAVE HER LINE RE-SITED. GIVEN ATIVAN .5MG IV X1 PER HO. SLEPT WELL AFTER LINE CHANGE. RESP: O2 SATS 95-97% ON RM. AIR. BS CLEAR. RR 12-19. CARDIAC: HR 70-72 AVP. BP 84-98/23-46. PAD 12-20, CVP 11, CO 5.7/3.33. DOPA 6MCG/KG->8MCG/KG D/T HYPOTENSION & LOW U/O. R. FEMORAL SWAN D/C'D. RIJ TRIPLE LUMEN PLACED. CXR DONE, & PLACEMENT CONFIRMED. HEPARIN RESTARTED 3HRS AFTER LINE PLACEMENT, & INFUSING AT 850U/HR. HCT 35. GI: ABD. DISTENDED. BS HYPOACTIVE. NO STOOL. GU: FOLEY -> CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 65->20CC/HR. INCREASED TO 30-100CC/HR AFTER INCREASING DOPA. ID: T(MAX)98.7(PO). AM LABS PENDING. ||||END_OF_RECORD START_OF_RECORD=1||||59|||| Neuro: Pt is A&O to TPP, pt moves all extremeties well. Pt OOB to chair, and camode many times! Cardiac: Pt HR is AV paced, BP in 80's. Tolerating well. Pt has a R IJ TL. Pt on 8mcg dopa, will go home on dopa, pt on 1400u/hr heparin. PTT theraputic. Resp: Pt on RA O2 sat in high 90's. BS clear. GI: Pt is on cardiac diet. Pt to camode many times, +BS pt has very hard pellets of blak stool, guiac pos. Pt may need to be disimpacted. Abd soft nt. GU: Pt has f/c adequate urine output with the 8mcg dopa. Misc: pt will be evaluated for picc, for home with dopamine. ||||END_OF_RECORD START_OF_RECORD=1||||60|||| PT IS ON 850U/HR HEPARIN NOT 1400U/HR. [**Doctor First Name 27**] ||||END_OF_RECORD START_OF_RECORD=1||||61|||| S: " My legs hurt " O: HR 70-72 AV paced. BP 84/40 at 2000, increasing to 91-109/37-61 through rest of night. dopa at 8mcq, heparin at 850u/hr. u/o 30-50/hr. c/o leg pain, stated good relief with one percocet. pt. c/o constipation. given colace. had large loose stool in eve, able to walk to bedside commode. then had uncontrolled diahrea ~ 12am, large amt. on floor, etc. assisted to commode. guiac pos. dark brown/black. up to commode twice since then but only passing gas or very small amt of stool. taking water and juice only. pt. requesting to stay up in cardiac chair through night. able to get up on own and to chair side commode with minimal assist. very steady on feet. no c/o dizziness. LS diminished. RA sat 96%. A: stable hemodynamics on dopa 8mcq diarhea s/p constipation P: hold stool softeners, follow lytes, VS. follow plan for dopa titration. ambulate in room as tolerated. ||||END_OF_RECORD START_OF_RECORD=1||||62|||| S/O: BP 88-104/30's, HR 71 AV paced. u/o 30-50/hr. (-) 250cc for 12am and currently ~ 70cc (-). Dopa at 8mcq and heparin at 850u/hr. pt. prefers to stay up in cardiac chair , more comfortable. also has had to use commode freq. so this makes it easier. - had 2 large loose brown stools in eve, discussed with HO and ordered immodium po for rx of diarrhea. given 2mg x1 and since then has only gone once for small amt. no c/o abd pain/cramps. passing gas. getting up on own, appears steady on feet. LS clear. RA sat 96%. asking questions about planned PICC line placement today and looking forward to going home this week hopefully A: stable rx for diarrhea P: PICC line today. immodium prn, dopa, heparin gtt as ordered. ||||END_OF_RECORD START_OF_RECORD=1||||63|||| pls see carevue flowsheet for complete vs/data/events s: no c/o cp, sob o: cv: hr 70s avpaced. k 3.6, 40meq given. bp 95-105/45-50. cont on dopa at 8mcg/min. tol well. enalapril cont at 2.5mg bid. no cp or sob. resp: ra sat 94-96%. rr 12-20, nonlabored. bs sl basilar cxs. gI: poor intake. no n/v. no bm this shift. gu: foley dc'd at noon. no void yet. act: to commode freq indep. amb approx 40yrds with walker and assist x1. tol well. ms: alert, cooperative. mae with purpose. hoping to go home later this week. dispo: full code. poss transfer to [**Wardname 28**]. plan picc or hickman placement(dr [**Last Name (STitle) **] to decide) when inr< 2.0(today 2.2). a: bp stable on dopa. p: follow uop, dtv. enc amb with assist. d/c planning. ||||END_OF_RECORD START_OF_RECORD=1||||64|||| s: i think i probably will say yes...i really have no other choices now. o: pls see carevue flowsheet for complete vs/data/events cv: hr 75 avpaced. bp 100-109/44-50. cont on dopa at 8mcg/min. tol enalapril up to 5mg bid. heparin infusing at 850u/hr. resp: bs dim at bases. sat 97-99% on ra. no sob. gu: voiding in commode. no diuresis. cr stable. wt 55.1. gi: fair po intake. no stool today. id: afeb. no abx. ms: pt spoke at length w/dr [**Last Name (STitle) **], dr [**Last Name (STitle) **], dr [**Last Name (STitle) 29**] today about prognosis and options. she appears to now understand that a transplant represents her best option for survival and that going home with iv dopa will be palliative and that she would not be expected to live more than a few months. she will speak further with her family and let dr [**Last Name (STitle) **] know her decision so plans can proceed for either option in the morning. a: bp stable. p: provide info and support to pt and family. cont to monitor rhythm, bp, uop. ||||END_OF_RECORD START_OF_RECORD=1||||65|||| Uneventful nite VSS. Remains on Dopamine @ 8mcg/k/min, Heparin @ 850u/hr. Slept well overnite in bed, rec'd 1 dose of 0.5mg Ativan for sleep after midnite w/ good effect. No c/o of CP or discomfort. see careview for details. ||||END_OF_RECORD START_OF_RECORD=1||||66|||| S-"I have agreed to go ahead with the transplant" O-Neuro alert and oriented x3, very pleasant and cooperative. c/o feeling tired and slept until 9am. Has agreed to have the heart tranplant work-up and Dr [**Last Name (STitle) 19**] team is coordinating the lab test and ultrasound (completed carotid and vascular ultraounds) Husband in this afternoon, somewhat supportive. CV-VSS remains on dopamine at 8mcg/kg/min with SBP 87-94/30's HR 70's AV paced. Resp-LS diminished, no O2 O2 sats 97%No SOB with minimal activity in room. ID-afebrile WBC 8.7 GU-voiding well in commode without assist. GI-Appetite good, no BM today. Activity-OOB room and chair most of the day. A/P-stable day,no c/o SOB. Have PT see pt QD to ambulate and do strengthing exercises. ||||END_OF_RECORD START_OF_RECORD=1||||67|||| Uneventful pm VSS. AVpaced 70. remains on DOPAMINE@8mcg/k/min, HEPARIN @ 850u/hr. am labs pending. Slept in bed overnite. Up to bedside commode. No voiced complaints. PLAN: con't to monitor VS. con't work up for heart transplant. offer emotional supports to pt + family. ||||END_OF_RECORD START_OF_RECORD=1||||68|||| S-"I can't believe this is all happening." O-Neuro alert and oriented x3, pleasant and cooperative. Asking appropiate questions about surgery. Feels sheis getting stir crazy and would like to go outside (weather permitting). Husband in and brought in steak that really picked her spirits up. CV-VSS dopamine remains at 8mcg/kg/min with stable BP 85-100/40. Resp-LS clear no SOB with activity. PFT's completed in lab. ID afebrile GU-voiding well on commode, weight remains stable at 55.1kg GI-appetite improved no BM today. Feels constipated after starting Fe. Activity- Physical therapy in and did some exercises with her and then went for walk in hallway. BP 78 after walking, although asymptomatic. No c/o chest pain or SOB. c/o general leg aching relieved with tylenol A/P-stable day. Encourage exercises in room. Possibly allow pt to go outside if weather OK over weekend. Goal keep weight stable at 55kg ||||END_OF_RECORD START_OF_RECORD=1||||69|||| S: " I want to go home " O: pt. teary eyed and upset in eve. feeling "stir crazy" and wanting to get out of room more. ambulated with walker around unit( with RN) and did well. felt better after. ativan .5po for sleep with good effect. dopa 8mcq. heparin 850u/hr. BP stable. voiding on commode. A/P: situational depression r/t hosp. ambulate more during day. ? assist outside with wheelchair. ||||END_OF_RECORD START_OF_RECORD=1||||70|||| bright spirits today, walking out of unit no s/sx card/resp compromise on heparin/dopa at constant doses eating/drinking/voiding independently husband in an updates continue all current supports-pre-heart transplant ||||END_OF_RECORD START_OF_RECORD=1||||71|||| NSG NOTE S:" I FEEL BETTER SITTING UP IN THE CHAIR" O: CARDIAC: 71,REMAINS AVPACED. SBP 89-117/40-78. CON'T ON DOPAMINE @ 8MCG/KG AND HEPARIN @ 850U/HR. DENIES CP. RESP: REMAINS ON RA STAS 99%. RR-REG 14-22 BS CL. DENIES SOB. GI: NO STOOL THIS SHIFT. C/O CONSTIPATION. DULCOLAX X2 TABS @ HS GIVEN. TOL PO'S DENIES N/V. ABD SOFT. GU: UP VOIDING ON COMMODE IN ADEQUATE AMT'S. SKIN: APPEARS GROIN RASH IS IMPROVING. SL REDDENED. DENIES DISCOMFORT. NEURO: IN GOOD SPIRITS. PLEASANT AND COOPERATIVE. ORIENTED X3 COMFORT: C/O BILAT FT PAIN D/T ACTIVITY. PERCOCET X2 TABS WITH GOOD EFFECT. ACTIVITY: OOB UP TO CH. AMBULATING UP TO COMMODE. TOL INCREASE ACTIVITY WELL. A: STABLE P: AWAITING W/U REGARDING HEART TRANSPLANT AM LABS SUPPORT WHEN NEEDED ||||END_OF_RECORD START_OF_RECORD=1||||72|||| S-"It felt good to take a shower" O-Neuro alert and oriented x3, very pleasant and cooperative. In very good spirits today. Took a shower and washed her hair and wore plain clothes all day. A friend of the pt came in today who had a heart transplant at [**Hospital 30**]. This friend was a great boost in her spirits and she asked good questions about the transplant. CV-VSS on dopamine at 8mcg/kg and heparin at 850u/hr PTT 59.9 Resp- LS clear O2 sats 97% on RA ID afebrile GU-voiding intermittantly on the commode weight stable GI-appetite good, no BM- having cramps Activity-OOB walking today in room and alittle in hallway. Alittle shaky but no SOB or pain. Did well in shower with supervision. Social-Friends into visit and husband in and brought pt pasta for dinner and clean clothes for Sunday. A/P-Stable day. Needs encouragement to do her exercises in her room. Follow HCT. ||||END_OF_RECORD START_OF_RECORD=1||||73|||| CCU NURSING PROGRESS NOTE 7P-7A NEURO: ALERT, ORIENTED X3, COOPERATIVE. GOOD SPIRITS. CV: HR 70'S AV PACED. BP 89-98/40'S. DENIES CP/PRESSURE. CON'T ON DOPA AT 8MCG/KG/MIN AND HEPARIN AT 850 UNITS/HR. WEIGHED THIS EVENING, ^59.5 (FROM 55.1) BILAT PEDAL EDEMA NOTED. PULM: LS CLEAR. DENIES SOB. GI/GU: ABD SOFT/DISTENDED. +BS. C/O CONSTIPATION. GIVEN MOM X1. NO BM THUS FAR. VOIDING VIA COMMODE. COMFORT: PERCOCET GIVEN FOR BILAT FOOT PAIN R/T ACTIVIT PLAN: CONT AWAIT RESULTS OF W/U RE: HEART TRANSPLANT. ? IF PT NEEDS TO RESUME LASIX. MONITOR LABS INCREASE ACTIVITY AS TOLERATED. SUPPORT AS NEEDED ||||END_OF_RECORD START_OF_RECORD=1||||74|||| S-"I spoke to the surgeon this evening" O-Neuro alert and oriented x3, slept until 11am felt she needed the extra rest. Was in very good spirits today. Surgeon from [**Hospital1 31**] in this eve to talk to pt. Pt felt much better talking to him this time c/w last time when she was not ready to talk about any surgery. c/o headache tyelnol 650mg po. CV-VSS on dopamine 8mcg/kg and heparin at 850u/hr. Noted HR increased this afternoon to 83-85NSR with PVC's. Resp-LS clear ID afebrile temp 99po GU-voiding intermittantly on commode. Weight stable at 55.5kg(55.1) GI-still c/o constipation took po dulcolax and might take ducolax PR this eve. Activity-OOB room and took walk this eve with husband around the unit. Still weak and requiring a walker c/o intermittant dizzines with walking. Social-husband in with clothes and dinner. A/P-Stable day, encourage pt to do exercises in room, OOB walking at least 3x/day. ||||END_OF_RECORD START_OF_RECORD=1||||75|||| NEURO: A&O X3. PLEASANT & COOPERATIVE. RESP: BS CLEAR. RR 11-23. CARDIAC: HR 82-88 SR WITH OCC. PVC'S. ~O5OO->HR 106-108 ST-ATRIAL BI- GEMINY. CONT. ON DOPA 8MCG/KG & HEPARIN 850U/HR. ABD US DONE- ? VENOUS MALFORMATION. GI: TOL. DIET WELL. ABD. SL. DISTENDED. BS+. BM X2 BLACK FORMED STOOL. GU: VOIDING QS CLEAR AMBER URINE. ID: T(MAX) 98.8(PO). PLAN: AWAITING HEART TRANSPLANT EVALUATION. ||||END_OF_RECORD START_OF_RECORD=1||||76|||| NSR C OCC PVC. BP 85 TO 98 SYS WHICH IS HER USUAL . LASIX 20 MG MIN RESPONSE . DOPAMINE CONTINUES AT 8 MIC. PTT 65. HEPARIN UNCHANGED . TRANSPLANT SX HAVE REQUESTED FEMOPAL ARTERIOGRAM C STENT IF NECESSARY.PT AGREES TO THIS . NPO P MIDNOC. HEPARIN WILL BE SHUT OFF IN XRAY . TRIPLE LUMEN NEEDED RESUTURING . AREA REDDENED . PT AMBULATING C PT . E/D FAIR. SEVERAL MED TO LG STOOLS GUIAC TRACE TO STRONGLY POS. HCT STABLE . ||||END_OF_RECORD START_OF_RECORD=1||||77|||| O: afeb. HR 80's SR. no VEA. BP 90-100/40. dopa 8mcq, heparin 850u/hr. ambulating around room with IV pump, tol. well. no dizziness. voiding on commode. requesting percocet for headache/leg pain with good effect. slept well through night. LS clear. RA sat 99-100% NPO after MN for fem. Agram. A/P: maintain NPO, ambulate TID , follow daily wts. , I/O. ||||END_OF_RECORD START_OF_RECORD=1||||78|||| S-"I hope this helps me" O-Neuro-alert and oriented x3, in good spirits today prior to arterial angiogram for BLE. Wants to go to [**Hospital1 31**] and wait for heart mostly because her room does not have a BR and it's too small. CV-VSS dopamine at 8mcg/kg with SBP 80-90/50 Heparin at 850u/hr PTT 51 Resp-LS clear no O2 no c/o SOB ID afbrile GU-voiding small amts in commode. Started .45NS at 50cc/hr before procedure and d/c'd it at 6pm. Plan to restart in am. GI-NPO/appetite good this eve. NO BM Skin- rash on abd, less itchy Activity-OOB chair most of the day. Needs to walk more! A/P-NPO after MN restart IVF at 50cc/hr at 8am. ||||END_OF_RECORD START_OF_RECORD=1||||79|||| NEURO: A&O X3. PLEASANT & COOPERATIVE. RESP: O2 SAT ON RM. AIR 99%. RR 13-22. BS CLEAR. CARDIAC: HR 86-94 SR-NO ECTOPY. BP 84-102/39-49. CONT. ON DOPA AT 8 MCG/KG & HEPARIN 850U/HR. PTT56.1. HEPARIN TO BE D/C'D IN AM PRIOR TO ANGIO. GI: TOL. DIET WELL. NPO AFTER MIDNOC FOR AGRAM. GU: VOIDING QS ON COMMODE. ID: AFEBRILE. AM LABS PENDING. PLAN: A GRAM THIS AM HEART TRANSPLANT ||||END_OF_RECORD START_OF_RECORD=1||||80|||| S I NEED A CIGARETTE .DO YOU THINK IT MATTERS NOW. O.RETURNED FROM CATH LAB 12 NOON. AORTIC BLOCKAGES BELOW RENAL ARTERIES NOT AMENABLE TO STENT. PT DEPRESSED AS THIS MIGHT DELAY OR EVEN PREVENT TRANSPLANT . CATH SITE L BRACHIAL MIN BLOODY STAIN ,SOFT , SL SWOLLEN . ARM BOARD TO BE DC 6PM. ULNA, RADIAL PULSE PRESENT BY DOPPLER . HEPARIN DRIP RESTASRTED 850 U 5PM S BOLLUS. TO RECEIVE 1500 CC 1/2 NS. LASIX 40MG GIVEN 5PM . BP 80 TO 90. CO DIZZYNESS P USING COMMODE . PLACEMENT OF LONG TERM LINE DISCUSSED C PT .IF SHE AGRESS LINE WILL BE PLACED BY IR TOMORROW .AWAITING DR [**Last Name (STitle) **] FOR CLARIFICATION OF PLAN. A AT RISK FOR FLUID OVERLOAD APPROPRIATELY DEPRESSED OVER CONDITION P MONITOR FLUID BALANCE ,NOT HO IF NO RESPONSE TO LASIX EMOTIONAL SUPPORT AS NEEDED ||||END_OF_RECORD START_OF_RECORD=1||||81|||| npn 7p-7a: ccu nsg progress note: s:"i'm doing fine" o: neuro--pt a&ox3, not talking much about results of yesterdays cath results of lower ext, sitting up in chair most of night, occ dozing off to sleep, moving w/out diff, did c/o pain to feet, given 1 percocet w/improvment in pain resp-ls cta, no c/o sob, ra sat 95-100%, rr 16-18, appears in nard cardiac--conts on dopa at 8mcg, hep initially at 850u/hr, ptt at 11pm 50.9, no bolus given & gtt increased up to 950u/hr, am ptt & labs pnd, no c/o cp, no dizziness tonight, bp 85-126/70's, pulses to l arm dopplerable, hand warm to touch, dsg to site w/sm old blood spot, no hematoma, ?what plan is today after dr[**Last Name (STitle) 32**] meeting at [**Hospital1 **] gi/gu--no issues, voiding w/out diff, has remained npo since mn for ?hickman placement ||||END_OF_RECORD START_OF_RECORD=1||||82|||| PT REJECTED FOR TRANSPLANT . CRYING AT TIMES . PLAN TO GO HOME ON DOPAMINE . TO XRAY FOR HICKMAN , NO T DONE DUE TO SEDATION ISSUES , WILL REATTEMPT TOMORROW . NPO P MIDNIGHT . DC HEPARIN 7AM . SEEN BY HOME NSG FOR PUMP SET UP . COUMADIN WILL BE STARTED P HICKMAN PLACED. HAS R BRACHIAL IV FOR USE IN XRAY TOMORROW . SEEN BY EPS FELLOW .PT IN FLUTTER.PACER INTERROGATED AND RESET .PRESENTLY IN AV PACED . BP STABLE ON 8 MIC DOPAMINE .HEPARIN STOPPED FOR PROCEDURE . RESTATED ON HEPARIN 3PM . TO HAVE FLU SHOT ,CONSENT IN CHART TO BE SIGNED . ||||END_OF_RECORD START_OF_RECORD=1||||83|||| npn 7p-7a: ccu nsg progress note: s:"i'm not getting the transplant" o: neruo-pt a&ox3, talking about her disappointment in not being a transplant candidate, mae, skin w&d, c/o pain to legs, med w/2 percocet, sleeping in chair most of night resp--ls cta, sat on ra 97%, no c/o sob/doe cardiac--hr av paced at 70's, no ectopy, pt states that she has not been feeling as tired or dizzy since pacer interogated and put back in av paced mode, bp 90-103/50, conts on dopa at 8mcg, hep at 950u/hr, plan for d/c of hep at 7am then to have hickman placed and start coumadin today gi/gu--voiding w/out diff, npo for hickman placment, (+)bs access--#20 iv in r ac to be used for meds while hickman being placed, to go for hickman this am, hep to be turned off at 7am social--pt talking about going home w/pump for dopa, her mother is to visit next week from fla, pt wants flu shot but would like to wait till after hickman placed ||||END_OF_RECORD START_OF_RECORD=1||||84|||| AWAKE AND ALERT VERBALIZING CONCERNS AND DISAPOINTMENT ABOUT TRANSPLANT DENIAL. ALSO VERY ANGRY ABOUT HICKMAN CATH PLACEMENT PROCEEDURE. CONT ON DOPA AT 8 MCG. BP STABLE CONT AV PACED NO VEA. LUNGS CLEAR. O2 SATS 98%. DENIES SOB. TAKING PO WELL. SMALL HARD STOOL. GIVEN MOM AND [**Name2 (NI) 33**]. WILL PROBABLY NEED DULCOLAX. ||||END_OF_RECORD START_OF_RECORD=1||||85|||| S. "I WANT TO GO HOME ON MONDAY!" O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: HR 70'S AVP, NO ECTOPY NOTED, DOPAMINE REMAINS AT 8MCGS/KG W/SBP REMAINING IN 90'S/ THROUGHOUT DAY; TOLERATING MEDS AS ORDERED HEPARIN AT 1050U/HR - PTT >150, OFF X 1 HR AND DOWN TO 800U/HR AT 2PM; COUMADIN 5 MG PO GIVEN, AMBULATING AD LIB IN ROOM RESP: RA SATS 98-100%, LUNGS CLEAR - DENIES SOB GI: TOLERATING CARIAC DIET IN SM AMTS - COLACE GIVEN -NO STOOL TODAY GU: VOIDING ON COMMODE, I/O'S ~ EVEN FOR DAY ID: TEMP MAX 98.1 PO SKIN: C/O DRY ITCHY SKIN, SLIGHTLY REDDENED ON UPPER BODY FROM SCRATCHING, EUCERIN CREAM APPLIED PRN BY PT, CLARITIN ORDERED X 1 SOCIAL: HUSBAND, OTHER FRIENDS IN TO VISIT OFF/ON THROUGHOUT DAY; TALKING ABOUT WANTING TO GET HOME ON MONDAY A: STABLE ON PRESENT MED REGIMEN - AWAITING DISCHARGE HOME ON IV DOPAMINE - ? MONDAY P: CONTINUE SUPPORTIVE CARE, MONITOR HR/RHYTHM, RECHECK PTT AT 8PM, DISCHARGE PLANNING/EMOTIONAL SUPPORT. ||||END_OF_RECORD START_OF_RECORD=1||||86|||| NPN 7P-7A: CCU NSG PROGRESS NOTE: S:"I AM GOING HOME ON MON!!!" O: NEURO--A&OX3, STATING THAT SHE IS ANXIOUS TO GO HOME ON MON, ASKING FOR PAIN MED FOR PAIN IN LEGS, GIVEN 2 PERCOCET W/GD EFFECT RESP--LS CTA, SAT ON RA 97-98%, RR 18 NOT LABORED, CARDIAC--HR 70'S AV PACED, NO ECTOPY, BP 91-94/50, CONTS ON DOPA AT 8MCG/HR, PTT SUBTHERAPEUTIC, PER PROTOCAL GIVEN 1200U BOLUS & GTT INCREASED TO 900U/HR, REPEAT PTT 89--WITH IN RANGE GI--TOL PO'S W/OUT DIFF, NO STOOL, REC'D COLACE/MOM GU--VOIDING W/OUT DIFF SOCIAL--STATING THAT SHE REALLY CAN'T WAIT TO GO HOME, AND MON IS WHEN SHE WANTS TO GO HOME ||||END_OF_RECORD START_OF_RECORD=1||||87|||| S. "WHAT'S MY INR - I WANT TO GET OUT OF HERE TOMORROW!" O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: HR 70'S AV PACED, NO VEA, BP 84-98/40-50'S TOLERATING ENALAPRIL, DOPAMINE REMAINS AT 8MCGS/KG VIA HICKMAN CATHETER, HEPARIN AT 900U/HR W/PTT 78.9 INR 1.5 ON COUMADIN 5MG QD RESP: RA SATS 97-98% W/CLEAR LUNGS GI: TOLERATING CARDIAC DIET IN SM AMTS, STOOL X 1 HARD ROWN, RECEIVING COLACE 2-3X/DAY GU: VOIDING WELL ON COMMODE, LASIX/ALDACTONE QD W/I/O'S ~ 500CC NEGATIVE TODAY; WEIGHT STABLE MS: A+O X 3, VISITING W/FAMILY MOST OF DAY, ANXIOUS TO GO HOME ASAP A: STABLE ON PRESENT MED REGIMEN - AWAITING DISCHARGE ON HOME DOPAMINE WHEN INR BECOMES THERAPEUTIC P: MONITOR HR, RHYTHM, BP CONTINUE MEDICAL REGIMEN, EMOTIONAL SUPPORT AND DISCHARGE PLANNING. ||||END_OF_RECORD START_OF_RECORD=1||||88|||| NEURO: AWAKE AND ALERT, SLEPT IN LONG NAPS DURING NOC. ANXIOUS FOR D/C HOME, CONCERNED ABOUT VNA CARING FOR HER AT HOME WITH DOPAMINE AND CODE STATUS. CV: BP STABLE ON 8 MCG/KG DOPA. TAKING ALL CARDIAC MEDS WITHOUT PROBLEM. HR 70'S AV PACED. NO VEA. DENIES CP. RESP: O2 SATS 99% ON RA LUNGS CLEAR. DENIES SOB. GI: SMALL STOOL GIVEN COLACE AND MOM, MAY NEED DULCOLAX OR PO LAXATIVE TODAY. APPETITE FAIR. GU: VOIDING CLEAR YELLOW URINE IN GOOD AMTS. OOB TO COMMODE. SKIN: SKIN ON UPPER TORSO REDENED AND ITCHY. GIVEN ALLEGRA PO FOR ITCHINESS WITH GOOD EFFECT.. NUMEROUS ECCHYMOTIC AREAS NOTED ON ARMS (PT. ON COUMADIN). HICKMAN CATH SITE CLEAN AND DRY. OOB TO COMMODE AND TO SIDE OF BED TO DO PRESCRIBED EXERCIZES BY PT. C/O PAIN IN LEGS, GIVEN 2 PERCOCET. ||||END_OF_RECORD START_OF_RECORD=1||||89|||| PT CONSIDERING CODE STATUS OF DNR.SEEN BY [**Hospital1 34**] NURSE FOR ARRANGEMENTS CONCERNING DOPAMINE PUMP.SHE SAY HUSBAND HAS GOOD UNDERSTANDING, MRS [**Known patient lastname 35**] FAIR .VNA NSG AGENCY HAS NOT ACCEPTED CASE.TO MEET [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36**] NURSING AGENCY WEN 9AM .INR NOT AT GOAL ,MUST BE . 2.0. PT STATES SHE IS LESS DIZZY BUT TIRED . AMBULATED IN HALL X2 . BP 90 OR ABOVE . AV PACED R. BS CL. SAT 98 RM AIR . HICKMAN CATH DSD CHANGED D/I . VOIDING QS C PO LASIX . E/D FAIR . REQUESTED DULCOLAX SUPP . LIDOCAINE PATCH TO ABD FOR PAIN. ALLEGRA FOR ITCHING. STABLE .DC TO HOME PLAN PROGRESSING SLOW BUT STAEDY ||||END_OF_RECORD START_OF_RECORD=1||||90|||| Pt while asleep slightly pulled out her hickman, a CXR has been ordered. Hickman still flushes and has good blood return. Con't to work with [**Doctor First Name 37**] for txr home. ||||END_OF_RECORD START_OF_RECORD=1||||91|||| awake ,alert ,oriented x3.ambulates around room without difficulty.remains avp with stable bp,dopamine continues at 8 mcq/kg/min.was able to ambulate around unit and out in the hall,tolerated well.skin warm and dry,with multiple ecchymotic and reddened blotches on arms.remains avp at 72 without ectopy. heparin continues at 800 units/hr and coumadin dose has been increased tonight .breath sounds clear,with nonproductive cough,sp02 97% on ra,resp rate in the 20s.abd soft with positive bowel sounds.eating full diet and supplemental drinks.appears to be constipated,had stool softner,refused suppository,was given bisacodyl 10 mg po.remains on daily lasix,voiding clear yellow urine.hickman cath placement was verified by xray,dsg around insertion site was changed for small amount of old serrosanguinous drainage,ports were flushed with ns and heparin per protocol.seen and evaluated by dr [**Last Name (STitle) **].talked with [**Doctor First Name **] from case management about arrangements for home,questionable family meeting planned for tomorrow. visited by husband,multiple phone calls from family and friends. pt agrees to status of dnr. ||||END_OF_RECORD START_OF_RECORD=1||||92|||| hickman cath examined by interventional radiology,cath ok.dr [**Last Name (STitle) **] spoke with husband and pt family meeting in am. ||||END_OF_RECORD START_OF_RECORD=1||||93|||| S-"I'm going home on Thursday", "I hope to live until my daughter's wedding". O-Neuro alert and oriented x3, in good spirits and very talkative about POC and appears to be OK with it. Although getting mixed messages about how long she is expected to live. Her daughter's wedding has been moved up so she can attend this year. Moved her to a room in the unit with a bigger window and this made her very happy. Comfort- having increase pain in her right leg/foot asked for percocett x2 and slept most of the night in the bed with leg elevated. CV-VSS on dopamine at 8mcg/kg and heparin t 800u/hr. Started coumadin received 10mg po last evening. Resp- LS clear NPC ID afebrile GU-voiding infrequent moderate amts of urine in commode GI-appetite good LBM [**08-01**] Activity-OOB walking in hallway with minimal assist. Mentioned that she has approx 10 stairs to the bathroom in the house. Possible have P.T. work with pt on the stairs Wed/Thurs. Access-hichman catheter site scant amt of blood, dressing changed and retaped to prevent pulling while OOB. Social-friends into visit and son came into also this evening. Discharge planning- family meeting at 9am. Husband to arrive at 8am. Discussion about care at home. Hospice/VNA visits.. on dopamine gtt. A/P-stable night prepare pt/family for pt discharge to home ||||END_OF_RECORD START_OF_RECORD=1||||94|||| S IN RESPONSE TO QUESTION " ANY PROBLEMS WE [**Name2 (NI) 38**] DISCUSSED? ""NONE EXCEPT I'M DYING." OPT MET C HOSPICE AGENCY . PLAN FOR DAILY VISITS TO START. WILL ALSO HAVE HOME HEALTH AID AND PT. WALKER/COMMODE ORDERED . MEDICATIONS DISCUSSED C PT,PRESCRIPTIONS WRITTEN .OPERATION OF HOME PUMP REVIEWED C FAMILY .PT TO GO HOME C HUSBAND 930 AM . NO DIZZINESS, BUT FATIGUED. AMBULATED X2 IN HALL . E/D FAIR. LARGE AMT OF STOOL TRACE QUIAC. VOIDING QS. WT 54.8 . A READY FOR D/C HOME P HAVE BLOOD WORK RESULTS PRE D/C ||||END_OF_RECORD START_OF_RECORD=1||||95|||| S-"I am so exhausted after all the visitors" O-Neuro alert and oriented x3, anxious about going home. Tired after a busy day with family meeting and visitors (missed her nap) Voicing some concern about family expecting her to do more at home than she can, and having to entertain visitors at home. Also afraid about having the infusion pumps alarming and no one is around to help her. Awake at 1pm and made pt go to bed and rest. c/o headache and right foot ache received percocett 2tabs. CV- VSS on dopamine 8mcg/kg and heparin at 800u/hr PT/INR pnd 6am. Resp- LS clear no c/o SOB ID afebrile GI appetite good, LBM [**08-02**] GU-voiding intermittant moderate amounts dark amber urine Skin- c/o itching arms/legs. +rash on chest from adhesive tape. Activity- walking in room, did not want to walk in hallway-too tired. A/P-Stable night and ready to go HOME today. ||||END_OF_RECORD START_OF_RECORD=1||||96|||| CORRECTION: Pt on lasix drip not insulin drip. ||||END_OF_RECORD START_OF_RECORD=1||||97|||| addendum: u/o improved to 220-250cc/hr. BP dropping to 70/30 at 0500. pt. also sleeping heavily although does wake easily. dopa increased to 10mcq and BP up to 84-96/40. HCT 29. PTT 70. ||||END_OF_RECORD START_OF_RECORD=2||||1|||| resp note - pt. transferred from cat lab to ccu. Pt. intubated with #8et tube 22at the lip, placed on 7200 ventilator ac tv 700 rr 15 70% fio2 5peep Spo2 100% hr 80 at this time. ||||END_OF_RECORD START_OF_RECORD=2||||2|||| 74 YO WOMAN TRANSFERRED FROM [**Hospital 39**] HOSPITAL FOR CATH/ACUTE MI. PMH: CAD WITH NQWMI [**02-07**], HTN, SUBCLAVIAN STEAL WITH R SBP 40 POINTS LOWER THAN LEFT SBP. EF 50%. EPISODIC EXERTIONAL DYSPNEA AND ANGINA. HPI: PT IN USOH UNTIL [**05-20**] WHEN PRESENTED AT [**Hospital 39**] HOSPITAL WITH SEVERAL HOURS OF SEVERE ABD PAIN AND NAUSEA. POS RUQ TENDERNESS AND INC LFT'S AND LIPASE, ? GALLSTONE PANCREATITIS. PT STARTED ON ABX AND CONSIDERING ERCP. TROP POS AT 5.2 FOR NON-Q WAVE MI AND TRANSFERRED TO [**Hospital1 39**] ICU. AT 2A [**05-22**], PT HAD EPISODE OF FLASH PULM EDEMA REQUIRING INTUBATION, EKG SUPPOSEDLY SHOWED NEW ST DEPRESSIONS IN LAT LEADS. PT TRANSFERRED TO [**Hospital1 2**] FOR CATH. EKG REVEALED TO HAVE LIMB LEADS SWITCHED, NO NEW CHANGES. CATH SHOWED SEVERE LAD AND DIAG DISEASE WITH INC RIGHT HEART PRESSURES, PT BALLOONED AND TRANSFERRED TO CCU. CV: IABP INITIALLY ON 1:1. AUGMENTING 0-12, UNLOADING 0-6. TOL WEAN TO 1:2 BUT SWITCHED BACK TO 1:1 FOR NOC. RIGHT GROIN SITE WITH SOME OLD BLOOD, NO HEMATOMA PALPATED. PULSES DOPPLERABLE AND SOMETIMES PALPABLE, FEET WARM EXCEPT FOR COOL TOES. PA CATHETER IN RA BY CXR, PULLED AT 1600 BY HO. MAPS 68-80'S. HR 70'S-80'S SR NO VEA. HEP STARTED AT 1000U, AGGRESTAT CONT AT 25CC/HR. PROPOFOL STARTED AND TITRATED TO COMFORT. REC'D KCL, CALCIUM REPLETION. RESP: INTUABTED ON 55% 700 X 15, NO SPON BREATHS. SCANT YELLOW SPUTUM, SPEC SENT. LUNGS WITH CRACKLES BILAT BASES, OTHERWISE CLEAR. LASIX 20 MG GIVEN X1 AT 1400 WITH MOD OUTPUT SO FAR. NO ABG SENT BY NURSING B/C NO A-LINE. ID: T 103.4 RECTAL, TYLENOL GIVEN X1. LEVO, OXI AND FLAGYL ALL STARTED. PT PAN-CX'ED. GI: NGT TO LIS, DRAINING BILE, OB POS IN SMALL AMOUNTS. PROTONIX TO START. HYPOACTIVE BS, NO STOOL. NPO FOR NOW. ABD U/S DONE. HCT 27. GU: FOLEY DRAINING CLEAR URINE. US WITH FLUID IN DOUGLAS POUCH, GYN CONSULT MS: SEDATED ON PROPOFOL, SPOKE TO 3 SONS TODAY, ALL FEEL THEY HAVE HAD SITUATION ADEQUATELY EXPLAINED. A/P: STABLE POST CATH, FOLLOW TEMP ON TYLENOL. CONT WITH LYTE REPLETION, PT NEEDS PRBC TONIGHT. WILL REPEAT LASIX IV. WAITING FOR MAGNESIUM TO BE SENT FROM PHARMACY. FOLLOW SEDATION LEVEL. ||||END_OF_RECORD START_OF_RECORD=2||||3|||| PT. INITIALLY ON AC 700X15/5/40%. ABG DRAWN 128/30/7.52 RR DECREASED TO 12. PT. REMAINS SEDATED TOLERATING CURRENT SETTINGS. BS: DECREASED ANTERIORLY NO SXN'ING THIS SHIFT. ||||END_OF_RECORD START_OF_RECORD=2||||4|||| O:NEURO=SEDATED W PROPOFOL GTT-INCREASED FROM 12 TO 24MCG & REQUIRING PRN BOLUSES DUE TO INCREASED AGITATION. RESPONSIVE TO NOXIOUS STIM, BUT DOES NOT FOLLOW COMMANDS. SOFT RESTRAINTS BILATERALLY. PULM:VENTED. SETTINGS-AC, 700X12, 40% & +5. SATS UPPER 90'S. LAST ABG-119/36/7.47/27/2. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TAN SECRETIONS. CV=HEMODY STABLE. IABP R-FEM--EXCELLENT AUGMENTATION & SYST UNLOADING. #'S-AS 90-124, AD 122-134, BAEDP 44-78. IABP M 86-108. SETTING CHGED FROM 1:1 TO 1:2 @ 0600. PT/DP PULSES DOPPLERABLE. SM AMT OLD BL UNDER IABP DSG. GTTS-AGGRASTAT @ 0.118MCG. & HEPARIN @ 1200U (INCREASE FROM 1000U FOR SUBTHERAPUTIC PTT). GI=NGT TO LCS-BILIOUS. GU=LASIX 40MG @ 2000. I&O +.6L @ 2300 & +.28L @ 0500. HEME=TX W 1URBC FOR HCT 27.3-POST 29-AM 27.4 (SET UP FOR 2U). ID=T MAX 100 PO. LABS=K REPLACED W 40MEQ IV. AM LABS PENDING. A:NOT IABP DEPENDENT. CONTIN DECREASE IN HCT. P:MAINT ADEQ SEDATION TILL IABP OUT & READY TO WEAN/EXTUBATE. PULM TOILET. WEAN IABP W GOAL DC. DC AGGRASTAT @ 1000. FOLLOW I&O-?AUGMENT DIURESIS W LASIX. ?TX W RBC FOR HCT 27.4. CK AM LABS-RX AS INDICATED. SUPPORT AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=2||||5|||| REVIEW OF SYSTEMS- NEURO- PATIENT SEDATED ON PROPOFOL DRIP AS PER FLOWSHEET. DOES OCCASIONALLY OPEN EYES TO PAINFUL STIMULI. GETS SLIGHTLY AGGITATED WHEN NEEDS TO BE SUCTIONED ONCE SUCTIONED SHE SETTLES BACK DOWN. RESP- REMAINS VENTED ON 40% FIO2, A/C OF 12, TV OF 700 AND PEEP OF 5. SATS IN THE HIGH 90'S. BREATHING 12 ON 12. SUCTIONED FOR THICK TAN SPUTUM. CARDIAC- HR IN THE 60-70'S NSR WITH RARE PVC. SBP 130-160'S. BALLOON PUMP DC'D AT 11AM. RIGHT FEM SITE WITH ACE PRESSURE DRESSING. SITE C AND D AND SOFT. DOPPLER PEDAL PULSES. HEPARIN AND AGGRESTAT DC'D TODAY PRIOR TO D/C OF BALLOON PUMP. CK SENT AT 1515 TODAY DUE TO NEW EKG CHANGES NOTED ON EKG THIS AM. RESULTS PENDING. CONTINUES TO BE DIURESED. RECEIVED 60MG IV LASIX. SHE IS PRESENTLY 373 NEG AFTER 2 U PRBC. STARTED ON CAPTOPRIL TODAY RECEIVED 12.5MG WITH SBP GOING FROM 150 TO 129. TO GET A 25MG DOSE THEN TO BE INCREASED TO 50MG TID. GI- NG CONTINUES TO DRAIN BROWN MATERIAL THAT IS GASTRO POS. ABD SOFT DISTENDED WITH POS BS. RECEIVED 2 U PRBC FOR HCT OF 27 THIS AM WITH OUT SIGNS OR SYMPTOMS OF REACTION. REPEAT HCT POST TRANSFUSION 38. SEEN BY GI TODAY. THEY FEEL SHE IS CLINICALLY IMPROVING WITH DECREASING LFT'S, LIPASE, AND WBC. ALSO FEVER CURVE IS DONE. SHE CONTINUES ON ANTIBIODICS. ABD U/S FROM YESTERDAY NEG FOR CHOLOCYSTITIS. SOCIAL- SONS IN VISITING TODAY. THEY WERE UPDATED BY CCU TEAM. GU- FOLEY PATENT DRAINING CLEAR YELLOW URINE. ||||END_OF_RECORD START_OF_RECORD=2||||6|||| resp note - pt. remaines intubated and mech ventilated, ac tv 700 rr 12 40% fio2 5 peep, tol ok at this time. ||||END_OF_RECORD START_OF_RECORD=2||||7|||| CARDIAC- CK DRAWN AT 1515 373. DR [**Last Name (STitle) 40**] AWARE. ||||END_OF_RECORD START_OF_RECORD=2||||8|||| npn 7p-7a: ccu nsg progress note: neuro--conts sedated on propofol, at times is able to open eyes to name being called and able to follow commands, other times just moves to painful stimuli and grimaces face to pain resp--ls coarse throughout, sxn'd for thick tan/white secretions, conts vented, no changes made during the noc, does not have an aline to follow abg's, sats 97-98%, rr 12, occ breaths over 2-4 breaths cardiac--hr 60-70 sr w/occ pvc's, bp 110-148/50, r groin site intact, no bleeding noted, (+)dopplerable pulses bilat, conts on captopril, bp does drop sl after getting dose gi--abd obese, (+)bs, (+)flatus, no stool, ngt to lis, draining brown material gu--foley to gravity, draining clear yellow urine id--spiked to 102.2r during noc, 2 add bld cx sent, given tylenol w/no change in temp, conts on ivab ||||END_OF_RECORD START_OF_RECORD=2||||9|||| NEURO: remains lightly sedated on Propofol gtt @ 36mcg/k/min. pt obeyed commands for family. opens eyes to stimuli. bilat arm restraints. CARDIAC: SR 60s. BP stable. repeat HCT this afternoon 35.3. dopplerable pedal pulses. R groin dsg removed, bandaid applied over old IABP site. ACCESS: 2 x #20g IVs in LLA. RESP: LS coarse. AC 700x12, Peep 5, 40%... ABG: 123/37/7.44/26. then rate decreased to 8 and pt overbreathing vent w/ RR 10-12. SX: for small to mod amts thick white secretions. GI/GU: foley patent clear yellow urine. approx 30cc/hr. Abd large/obese, distended. +BS. +Flatus. no stool. OGT patent, for bilious brown drainage. remained NPO today, OGT clamped for meds. PLAN: for CT of ABD this afternoon. con't to monitor vitals. con't to wean on vent ?plan extubation tomorrow? ||||END_OF_RECORD START_OF_RECORD=2||||10|||| Resp. care note: Pt stable through the shift. Resp. rate was decreased from 12 to 8bpm. pt suctioned for a small amount of thick secretions. plan is for patients to have CT scan of abd. sometime this evening. FOr further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=2||||11|||| npn 7p-7a: ccu nsg progress note; neuro--conts sedated on propofol w/gd effect, pt is able to open eyes when name called and follow simple commands, sleeping on/off most of the noc resp--ls coarse throughout, sxn'd q1-2hrs for thick white secretions, pt noted to have increased coughing, sats 98-99%, occ overbreathing vent by 3-4 breaths cardiac--hr 60-70's sr, occ pvc's noted, bp 133-179/50, conts to rec lopressor/captopril/isordil, gi--abd obese, soft/distended, (+)bs, (+)flatus, abd ct done which showed ?gallstone, conts npo, is rec'ing meds via ngt gu--foley intact, draining lg amt of clear/yellow urine after given lasix id--conts febrile up to 101r, team aware, conts on ivab, cx's still pnd, ?source of fever access--pt has 2 peripheral iv's, is difficult access for blood draws, would benefit from picc line! ||||END_OF_RECORD START_OF_RECORD=2||||12|||| Pt. weaned via PSV down to 5/5/ Leak test positive. Pt. extubated onto 40% cool aerosol face tent. Spo2 97% RR 16, some mild stridor noted, dr [**Last Name (STitle) 41**] aware. however pt. has strong cough and is tolerating well at this point. ||||END_OF_RECORD START_OF_RECORD=2||||13|||| HPA: This pleasant 74y old woman went to [**Hospital 31**] Hosp [**05-20**] with sever abd pain and nausea. She had RUQ tenderness and elevated LFTs and lipase. However her troponin came back at 5.2 and she R/I for non-Q wave MI. At 2am [**05-22**] she developed flash pulmonary edema and required intubation. They saw new EKG changes (which were later shown to be improperly placed EKG leads.)She was transfered to [**Hospital1 2**] for cath and was found to have severe LAD and diag disease with collaterals. They attempted to open the diag and were unable to. They felt none of the lesions were acute and inserted an IABP. She had elevated filling pressures and have an had IABP inserted with plans for diuresis. She was transfered to CCU for further care. ALLERGIES: tomatoes, codiene PMH: CAD: NQWMI 13. HTN. EF 50%. Exertional angina and dyspnea. Subclavian steal syndrone with L BP ~40p higher than L. CCU COURSE: ID: Pt spiked to 103.4 on [**05-22**] and was fully cultured. She is on levofloxacin, ampicillin and flagyl. She spiked to 101R on eve [**05-23**]. T-max today was 100.8R. CV: Pt has remained painfree. Her IABP was d/c [**04-22**]. Her groin remains dry. Her HR has been in the 70-80s and her lopressor will go up to 50mg tonight. Her BP has been stable in the 120s-140s/40-50 taken on her R arm. Her captopril was increased to 75mg po at 6pm and she has tolerated it. She will go up to 100mg tid at 2am. RESP: She was extubated easily at 2pm [**05-25**] and is now sating 98% on 4L NP. She is still [**Last Name (un) 42**] up viscous sputume from the back of her throat. She has a strong cough. Her breathing feels comfortable. GU: She has been diureses--last time at 2am [**05-25**]. She is presently 2 liters neg today and 4.7 Liters neg LOS. GI: Pt has been NPO since she has been here. She had some G+ asp. She has had and ultrasound neg for cholecystitis and CT thant showed gallstones, but no obstruction at this time. He LFTs have gone down.Pt had small G- liquid stool. She has been taking liquids but apetite is still poor. ENDO: FS have been in normal range. However at 6p [**05-25**] she was 205 and received 2u reg insulin. HEME: Her crit had dropped to 27 on [**05-23**] and she received 2U PRBCs. Her crit has since been stable. Last crit on am of 8/28 was 36.6. MS: Pt is now alert and oriented times three and extremly pleasant. SHe was OOB to chair and while she can weight bare she does have difficulty taking steps. She needs to be seen by PT this weekend to see if she needs rehab. PLAN: CV: She will need stress test to see if another attempt at intervention is needed. Maximise medications. She may recieve stents to both L and R subclavian arteries. It has been discussed with her, but she wants more time to think about it. GI: Once she has recovered she will be evaluated for probable ERCP. REHAB: She should be seen by PT. She has been seen by case manager and if she needs rehab there is one very near her home. ||||END_OF_RECORD START_OF_RECORD=2||||14|||| npn 7p-11p: pt conts a&ox3, mae, skin w&d, talking/drinking fluids w/out diff, ls cta, sat on 4l 97-100%, rr 16-18, not labored, does not appear in any distress. hr 70's sr, no ectopy, bp 150-170/60's. pt to be transfered to floor. to go to [**Wardname 43**]. ||||END_OF_RECORD START_OF_RECORD=2||||15|||| Cardiac: CK elevating 932, Troponin decreasing to 5.7. ?CK pt remains afebrile.leak? PLAN: con't to cycle CK+MB/Troponin ||||END_OF_RECORD START_OF_RECORD=3||||1|||| Resp Care pt intubated in eu for airway protection..swelling of upper airway seem by eu physicians. 7.5 ett taped 23 lip. sxned for thick yellow tinged sputum. transferred to ccu and placed on ac mode 700x12x1.0/5 peep. abg,cxr pending. bilateral bs. ||||END_OF_RECORD START_OF_RECORD=3||||2|||| 67 YO FEMALE ADMITTED TO CCU FROM THE EW WITH ?LITHIUM TOXICITY. PMH:CHRONIC DEPRESSION. HYPOTHYROIDISM. CHRONIC RENAL INSUFFICIENCY. LITHIUM TOXICITY-[**1995-05-30**]. ALLERGIES:NKDA. SOCIAL:MARRIED-WO CHILDREN. UNEMPLOYED. HUSBAND CEO OF [**Company 44**]. SMOKER 30PK/YR. WO ETOH. PRESENT HX:PRESENTED TO EW [**05-22**] @ 1230 W LETHERGY, CONFUSION, & DEHYDRATION X5 DAYS. IN EW FOUND TO HAVE INCREASED CALCIUM/BUN/CREAT, ELEVATED LITHIUM LEVEL & BRADYCARDIA WO HYPOTENSION-AGGRESSIVELY RXED W IVF APPROX 7L & ATROPINE .5MG X1. PAN CULTURED-ABX LEVOQUIN X1. LP/CT HEAD/CXR DONE. INTUBATED FOR DECREASED MENTATION & AIRWAY PROTECTION. ADMITTED TO CCU [**05-22**] @2330. O:NEURO=UPON ADMISSION AGITATED-NOT RESPONDING TO VERBAL STIMULI. PROPOFOL STARTED & TITRATED TO ADEQ SEDATION. SOFT RESTRAINTS UPPER EXTREM. SIDERAILS UP. PULM=INTUBATED & VENTED. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS. SATS ON 100%-100%. AFTER ALINE INSERTED-ABG SENT (SEE FLOW SHEET)-FIO2 DECREASED TO 50%. CV=BRADYCARDIC W HR @ X'S TO UPPER 30'S-BORDERLINE HYPOTENSIVE BY CUFF-IVF WIDE OPEN. EKG-CHB W JUNCTIONAL ESCAPE RHYTHM. CENTRAL LINE PLACED-RFEM-DOPA GTT STARTED A 5MCG/KG/MIN-SUBSEQUENTLY HR INCREASED TO UPPER 60'S/LOW 70'S W INCREASE IN BP. GI=OGT PLACED-BILIOUS MATERIAL-GUIAC NEG. FOLEY=MINIMAL UO. URINE SENT FOR LYTES. W STABLIZATION OF BP-LASIX 40MG GIVEN W ADEQ RESPONSE. ID=AFEBRILE. WO ABX-AWAITING CULTURES. LABS=UPON PLACEMENT OF ACCESS LINES-LABS SENT. CA ELEVATED-RXED W PAMIDRONATE IV. LITHIUM LEVEL SENT. ACCESS=PERIPHERAL LINES X2-#18 & 20. INTRODUCTER PLACED R-FEM. ALINE PLACED L-RADIAL. A:ELEVATED LITHIUM LEVEL UPON ARRIVAL TO EW-?CAUSE OF S/S. P:ADEQ SEDATION. ADJUST VENT AS INDICATED. PULM TOILET. CONTIN LOW DOSE DOPA-RATE MANAGEMENT. MAINT IVF-AUGMENT DIURESIS W LASIX AS NEEDED. FOLLOW CULTURES. RECK LITHIUM LEVEL-?DIALYSIS IF REMAINS ELEVATED. AM LABS. SUPPORT FAMILY AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=3||||3|||| Patient is a 67 y.o. female admitted with lithium toxicity. Patientintubated in EW with 7.5 ETT for airway protection. Tube taped and secured at 23cm. Patient remains intubated and mechanically vented Vent checked and alarms functioning. Patient comfortable on vent. Settings: A/C 700*12 50% 5 peep. ABG 7.35/281/42/24/-2. Pa02 weaned to 50% with this gas. BS: clear and equal. Please see respiratory section of carevue for further data. Plan: Continue mechanical ventilation. Respiratory status stable on current settings. Wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=3||||4|||| CCU NPN See carevue for subjective/objective data. Neuro: Remains sedated with Propofol--initially at 50mcg/kg/min but titrated down to 20mcg/kg/min as pt unresponsive to painful stimuli at 50mcg/kg/min. Currently pt opens eyes to painful stimuli, some non-purposeful movement of hands, legs noted with tactile stimuli. PERL, 3mm, brisk. CV/Pulm: VS per carevue. MP=SB-->NSR 33-78. Isolated PVC noted. BP low 100's, occas dips to high 80's with MAP >65 until 1715 when BP dropped to 71/42 with MAP of 51. Dopa increased to 10mcg/kg/min with BP gradually increasing--currently with BP of 91/52 with MAP 64. KPhos 6.8mM hung at 1630--to infuse over 6hrs via femoral line. Remains vented with ABG's per carevue. Only vent change was this AM when rate decreased from 12 to 10 with rpt ABG's good. BS coarse bil. Suct for thick yel sec, sm amts q4h in addition to suctioning done by RT. GI/GU: OGT->LCS drng bilious material in lg amts. BS positive. No BM, no flatus. U/O qs q1h with brisk diuresis after Lasix. ID: Afebrile. Started on Levo and Ceftaz. Cultures from ED pending. Integ: Abrasion R knee-->no drainage. No other open areas noted. Psychosocial: Husband in to visit. Emotional support given to pt and husband. Per husband they do not have children and rarely see their family. ||||END_OF_RECORD START_OF_RECORD=3||||5|||| RESPIRATORY CARE: PT WITH 7.5 ORAL ETT AT 23 LIP. CONTINUES ON A/C 10/700/.50/5 WITH NO RECENT ABG. LAST ABG STABLE. QUIET NIGHT FOR PT. [**First Name11 (Name Pattern1) 45**] [**Name7 (MD) 46**], RRT ||||END_OF_RECORD START_OF_RECORD=3||||6|||| NEURO: remains sedated on PROPOFOL 29mcg/k/min. nonpurposeful movement, opens eyes to noxious stimuli. bilat wrist restraints. CARDIAC: SB/SR 50-110s. no ectopy noted. BP labile overnite, titrating DOPAMINE 8-12mcg/k/min. Had cp, levines sign, better when bp stable. Aline dampening often overnite, able to palpate pulses. This morning, aline dampened and was unable to draw labs off line, site looking worse, pulse harder to palpate, HO notified. aline d/c'd. HO attempting to place new aline at this time. R femoral introducer intact. able to palpate radial pulse in old aline site since aline d/c'd. ID: Tmax 100.8. On Levo + Ceftaz Q24h. RESP: AC 700x10, 50% 5 peep. SX large amts thick yellow secretions. LS coarse. unable to obtain am abg until new aline inserted. GI/GU: autodiruresed overnite large amts clear yellow urine. Foley patent. +BS. OGT to low constant suction, for greenish bile. quiac neg. remains NPO. PLAN: attempt to wean off dopamine as tolerated. monitor hemodynamics. placement of new aline. ??place TLC over wire thru R femoral introducer site?? monitor temps. ||||END_OF_RECORD START_OF_RECORD=3||||7|||| RESPIRATORY CARE: PT. WITH 7.5 ORAL ETT AT 23 LIP. CONTINUES ON A/C 10/700/.50/5 WITH STABLE ABG. SX. THICK YELLOW SPUTUM. [**First Name11 (Name Pattern1) 45**] [**Name7 (MD) 46**], RRT ||||END_OF_RECORD START_OF_RECORD=3||||8|||| no changes today on heated system from [**Hospital1 47**]. ET tube found at 20 cm at lip. BBS clear and equal. ||||END_OF_RECORD START_OF_RECORD=3||||9|||| MICU Nursing Progress Note 7a-7p: Neuro: Pt conts to be sedated on propofol gtt currently at 45 mcg. Pt arouses to painful stimuli. Sedation weaned to assess pt's neuro status pt opening eyes spontaneously and not following commands. Pt kicking legs off bed and pulling arms towards ETT. CV: SB HR 36-53 no ectopy noted. Labile BP on dopamine gtt. Dopamine gtt weaned from 5mcg to 3.5mcg/kg/min. On 3.0mcg SBP in the 80's up to 100 on 3.5mcg/kg/min. Secondary to hypotension and bradycardia temp wire paced at the bedside under fluro in L fem by EP fellow. VVI paced rate 80 ma 7. Sensitivity ma 2. No improvement in BP s/p pacer wire placement, see carevue for objective data. CXR and EKG preformed to verify placement. BP transiently to 170's with sunctioning and position changes. K+ 3.4 repleted with total 80meq KCL via OGT. Repeat K+ 3.4 on blood gas. Ca 8.7 PULM: Mechanically ventilated on AC 700x10 Fi02 40% 5 peep. ABG on these settings 191/31/7.40/20. Pt sxn'd for thick yellow sputum. treating pt for pnx with levo and ceftax IV. No peripheral edema. noted. GI: Abd soft NT +BS. No stool this shift. Nepro TF currently at 20cc/hr goal rate 30cc/hr and then add promod per nutrition consult. Pt with minimal residuals. JP minimal out. GU: Foley cath patent draining cyu. BUN 37(43) Creat 2.3(2.6). +4701 LOS +3042 since mn. Fluid status goal is postitve per team. ID: temp max 99.0. BC pending. Conts on IV abx. SKIN: Buttocks intact. R knee abrasion. LINES: R fem introducer, await team to place TLC. L fem a-line and temp pacer wire 2 piv. PROPH: protonix iv and pneumoboots. DISPO: Full Code SOCIAL: Husband [**First Name8 (NamePattern2) 48**] [**Name2 (NI) 49**] in to visit. Team to contact other family members in [**Location (un) 50**]. A: Resolving lithium toxcity and hypercalcemia with ?septic etiology. Brady and hypotensive on dopamine gtt with temp pacing wire. P: Follow CV status, wean dopamine gtt as tolerated. EP following s/p temp pacing wire placement. Await orders to replete K and Mg. Cont current vent settings. Increase TF to goal. follow neuro status on sedation. ||||END_OF_RECORD START_OF_RECORD=3||||10|||| NEURO: CONT TO BE SEDATED ON PROPOFOL. WHEN LIGHTENING UP ON SEDATION PT. BECOMES AGITATED WITH LEGS KICKING UP IN AIR AND BITING ON ETT. NON-PURPOSEFUL MOVEMENT. MOVES EXTREMITIES ON BED. CV: BP STABLE ON DOPA OVERNIGHT. THIS AM PT. BECOMING SL. HYPOTENSIVE SYS 70-80'S WITH MAP57-63. DR [**Last Name (STitle) 51**] AWARE. DOPA INCREASED TO 5 MCG/KG/MIN. BP BETTER WITH INCREASED DOSE. RESP: CONT ON SAME VENT SETTINGS SEE VENT FLOWSHEET FOR DATA. ABG PENDING THIS AM. SUCTIONING FOR THICK WHITE - YELLOW SPUTUM. STRONG COUGH AND GAG. ORAL SUCTIONING FOR THICK MUCOUS. GI: ON TF NEPRO RATE 30 CC/HR WITH MIN RESIDUALS. HYPOACTIVE BS. NO STOOL OVERNIGHT. NO VOMITING. GU: URINE VIA FOLEY. CLEAR YELLOW IN GOOD AMTS. SKIN: INTACT EXCEPT FOR SMALL ABRASION. CLEANED WITH SOAP AND WATER. AND OPEN TO AIR. ||||END_OF_RECORD START_OF_RECORD=3||||11|||| CV: Remains on Dopamine, very dependent, range 6-10ug/kg, BP 90-120/, did drop to 65-70/ a couple times this AM, no precipitating events, each time responded to increased Dopa. Presently at 8ug/kg with BP holding more stable this afternoon. Remains V-paced with temp wire at rat of 78, increased today to 96 to see if it would help her pressure, did not, cont to have drops in pressure, turned rate back down to 78. MA increased from 7 to 10 by EP. Groin site D&I, no hematoma. K+ 3.3 this AM, given 40 mEqpo and 40mEq IV, repeat 4.2. Repleated with 2 GM MgSO4. RESP: Remains vented on AC 40% 700x10, 5 PEEP. Suctioned 2-3x for sm amt white thin secretions. LS Clear with a few scattered rhonchi. ID: afebrile, fully cultured today for survalence, cont to have septic picture with no clear ID source. Ordered for chest and abd CT today, barocat given, finished 2 bottles at 5:30PM. Remains on Levo and Ceftaz. GI: TF at goal, off for CT scan, formula will be changed to 3/4 str Nepro with promode at 30cc/hr. No stool today. Hypoactive BS. Neuro: sedated on 45ug of propofol, tried to decrease to 40ug, pt began moving legs around, bending. Did not follow commands, eyes opened spontaneously, did not track or focus. Soc: husband and son in , updated by RN and Sub I. ||||END_OF_RECORD START_OF_RECORD=3||||12|||| Respiratory Care: Brought pt to ct which was uneventfull. Placed on servo vent (same settings). [**First Name4 (NamePattern1) 52**] [**Last Name (NamePattern1) 53**] CRT ||||END_OF_RECORD START_OF_RECORD=3||||13|||| S/O: SEE VS/OBJECTIVE DATA PER CARE VUE. ID: T MAX 101.4, STARTED ON FLAGYL AND VANCO TO HAVE A WIDER COVERAGE OVER PRESUMED PNEUMONIA. DOWN TO CT SCAN WHICH WAS NEG EXCEPT FOR BILAT CONSOLIDATIONS WITH SMALL PLEURAL EFFUSIONS. NO GROWTH SO FAR FROM [**05-26**] CULTURES. CV: HR INITIALLY 78 VENT PACED, HAVING SOME INTRINSIC BEATS, TEAM DOWN TO ASSESS TEMP WIRE AND INCREASED RATE TO 100 WITH NO EFFECT ON BP, ALSO DECREASED RATE TO DETERMINE PT'S INTRINSIC RATE WHICH WAS IN THE 40'S, WITH RATE THAT LOW BP DROPPED TO LOW 80'S. PACER INCREASED UP TO 94. BP REMAINS VERY LABILE, ATTEMPTED TO WEAN DOPA BUT UNSUCCESSFUL, DOPA AT 12MCG/KG/MIN TO MAINTAIN SBP > 90. ALSO FLUID DEPENDENT, WHEN FLUID OFF FOR ANY TIME BP DROPS TO 80'S. TEMP WIRE VIA L GROIN REMAINS INTACT AND APPEARS TO BE SENSING AND PACING WELL. L GROIN WITH A LINE INTACT WITH GOOD WAVEFORM. RESP: ONLY VENT CHANGE MADE WAS TO DECREASE FIO2 TO 30%, CONTS TO HAVE GOOD SATS 99-100%. SUCTIONED X 3 FOR SMALL AMTS THIN CLEAR/WHITE SECRETIONS. LUNGS WITH SCATTERED COURSE AERATION. GI: ABD SOFT WITH GOOD BOWEL SOUNDS. NO BM. TUBE FEEDS RESUMED AT 30CC/HR TOL WELL, NO RESIDUALS. GU: HAS EXCELLENT URINE OUTPUT, UP TO 300CC/HR. URINE CLEAR, LIGHT YELLOW . MS: SHE IS OPENING HER EYES TONIGHT ON OWN AND TO VERBAL STIMULI. MOVES LOWER EXTREMS BUT NO MOVEMENT SEEN IN UPPER. SHE DOES NOT FOLLOW COMMANDS AND DOES NOT APPEAR TO TRACK. WRIST RESTRAINTS UNTIED. PROPOFOL CONTS AT 45MCG/KG/MIN. A: REMAINS VERY DOPA.IVF DEPENDENT ABLE TO DECREASE FIO2 TO 30% BILATERAL BASILAR PNEUMONIA NO CULTURE GROWTH/ADDED 2 IV ANTIBX P: ? EXTUBATE SOON WITH LITTLE SECRETIONS AND LOW FIO2 NEEDS CONT TO TITRATE DOPA AS TOL ||||END_OF_RECORD START_OF_RECORD=3||||14|||| Resp: No vent changes made, Sating 99% on 30%, Suctioned Q3-4hrs for thick white sputum. LS clear with bronchial BS at R base. CV: remains on Dopa, increased to 13ug/kg to keep BP 90's-110/, HR initially 93PMR, EP checking pacer found intrinsic rate to be 68-70 acelerated junctional, BP unchanged in this rhythm, left with pacer set at 50. Had few minutes of NSR ~5pm, BP shot up to 160/70. Attempted to wean Dopa quickly, BP dropped and pt went back into accelerated junctional rhythm requiring Dopamine back at 13ug/kg. K+ 3.2, repeated with 40mEq IV and 40mEq po. ID: Remains febrile, 101- 101.4 Rectal. Added vanco, flagyl to Levo ceftaz. BC from R groin line drawn on [**05-26**] came back with Gr(+) COCCI in pairs and clusters. Team placing TL, and will DC R groin line. Also needs RUA peripheral line DC'd. Cardiology planing to DC Pacing wire in AM if intrinsic rate remains stable. Neuro: eyes open, not following commands. Remains on Propofol decreased to 40ug from 45. Spoke with her psychiatrist, at baseline pt is A&Ox3, functional, has general anxiety, Bipolar-1. Agrees with holding psych meds at present. GI: tolerating TF at goal. No stool. BS active. FEN: UO brisk, keeping even with intake. IVF decreased to 100cc/hr so total intake with gtt is 100cc/hr. Repeated K, cont on neutrophos. A: Pt benefits from atrial kick. P: If requires pacer consider duel chamber pacer. cont to follow hemodynamics and titrate Dopa, cont AB, check culture results. Pul toilet. Remove groin lines ASAP. ||||END_OF_RECORD START_OF_RECORD=3||||15|||| O: SEE VS/OBJECTIVE DATA PER CARE VUE. ID: T MAX 102 RECTALLY, REC'ING TYLENOL, NO CHANGE MADE ANTIBX. R GROIN LINE DC'D. BC X 1 SENT FROM NEW TLC. CV: HR 55-70'S SR/JUNCTIONAL ESCAPE. BP VERY LABILE DEPENDING ON RHYTHM. WHEN IN SR BP INCREASED SIGNIFICANTLY AND ABLE TO DECREASE DOPA BUT WHEN CONVERTS TO JUNCTIONAL THEN BP PLUMMETS TO 60'S REQUIRING INCREASE IN DOPA BACK TO PREVIOUS DOSE. TEMP WIRE REMAINS INTACT VIA L GROIN BUT CURRENTLY NOT BEING USED. L GROIN D/I. RESP: NO VENT CHANGES MADE, CONTS AT 30%/700/AC10 PEEP 5. SUCTIONED FOR SMALL AMTS OF THIN WHITE SECRETIONS. LUNGS WITH SCATTERED COURSE AERATION. HAS MOD AMTS OF SECRETIONS IN MOUTH. GI: TOLERATING TUBE FEEDS WITH LOW RESIDUALS, NO BM. ABD SOFT WITH ACTIVE BOWEL SOUNDS. GU: CONTS TO HAVE EXCELLENT URINE OUTPUT, 200-300CC/HR. URINE LIGHT YELLOW/CLEAR MS: OPENS EYES SPONT, MOVES LOWER EXTREMS SPONTANEOUSLY AND TO PAINFUL STIMULI, DOES NOT FOLLOW COMMANDS. SHE IS NOT MOVING UPPER EXTREMS, EVEN TO PAINFUL STIMULI. DECREASED PROPOFOL. A: TEMP SPIKE GROWING GRAM (+) COCCI FROM BLOOD CULTURES CONTS TO HAVE LABILE BP DEPENDING UPON RHYTHM P: CONT TO TITRATE DOPA AS TOL FOLLOW TEMP ? RECULTURE IF SPIKES AGAIN ||||END_OF_RECORD START_OF_RECORD=3||||16|||| s: remains orally intubated. no attempts to verbalize o: pls see carevue flowsheet for complete vs/data/events id: t max 100.4r this shift. wbc 14.4.ceftaz dc'd. cont on flagyl, levo and vanco. cultures pend. with next fever spike will culture with fungal isolators as well. neuro: propofol weaned down overnoc and pt very alert this morning. able to follow simple commands. moving arms and legs weakly. req l leg immobilizer d/t fem aline/venous line and soft wrist restraints. propofol increased with some sm boluses for agitation, pt coughing, req freq sxn'ing for thin secretions, ^'d rr and moving arms, legs. propofol back up to 40mcg/kg/min. cv: cont in sr this shift. rate 58-65. occ pvc. no runs. fem venous pacing wire dc'd by cardiology fellow this am. k and mg repleted, will recheck this eve. weaning dopa slowly. now down to 7.5mcg/kg/min with bp 100-115/60 via l fem aline. this afternoon r rad aline placed by team. l fem a and v lines will be dc'd this afternoon with culture of tips. resp: changed to ps from ac this afternoon. currently on ps of 10. tv avg 400-450. rr 20s. sxn'd q 2hrs for thin clear to thick white secretions. bs occ coarse at base but otherwise cta. abg: 7.39/31/77/19/-4. sats 96-99% gi: tol tf nepro with promod at 30cc/hr. will change per nutrition to promote with fiber with goal to 50cc/hr. no stool since admit. given ducc supp but no stool in rectum. also given lactulose x1. colace ordered as well. abd is soft. +bs. gu: uop 150-250cc/hr. goal even for day but is currently 700cc-. ivf ^'d to 140cc/hr of 1/2ns. cvp 8-10. skin: intact. mouth with white patches. started nystatin s/s. social: husband visited and was updated by team. is encouraged by her progress today. a: sr, dopa dep, afeb p: follow rhythm and hemodynamics. wean dopa as hr and bp tol. d/c l fem lines. change tf. cont meds to produce bm. med for comfort/safety. support to pt and spouse. ||||END_OF_RECORD START_OF_RECORD=3||||17|||| Resp: Pt placed back on AC for high RR on PS, ABG stable. Suctioned for thin white secretions x3 this eve. Sats 97-99% on FIO2 30%. CV: Remains on Dopa, decreased to 6ug/kg. BP has remained 90's-low 100's/, IVF .45NS at 140cc/hr. If Dopa or fluid stops for any reason pt drops her pressure. Remains in NSR with rate 58-66. K+ 3.6, Mg 1.9 Neuro: alert, but looking dazed and following commands on 40ug of Propofol. Soft restraints on, pt comfortable and sleeping on and off. ID: AB increased for normal renal function. T 99.7 po. If respikes need BC with fungal isolator. GI: TF changed to Promote with fiber at 30cc/hr, to be advance to goal of 50cc/hr. Low residuals. Had 2 large BM's OB(-). First stool with formed stool mixed with loose, @nd stool loose, rectal bag placed. Nystatin to mouth for thrush. A: On decreased amount of Dopa, all groin line now out. P: cont to follow hemodynamics, cont pul toilet, follow lytes and repleat as needed. Sedate to comfort and safety. ||||END_OF_RECORD START_OF_RECORD=3||||18|||| S- OPENING EYES TO VERBAL STIMULATION; APPEARS TO HAVE SOME PURPOSEFUL RESPONSE(SQUEEZE HAND) TO REQUEST. O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAINS AT BASELINE HEMODYNAMICS WITH HR- 55-60 SB/SR. BP WHILE SEDATED, ASLEEP- 85-90'S/ WHILE AWAKE- 118/. REMAINS ON DOPA GTT 6MCG/KG. NO SIGNIFICANT EPISODES OF LABILE HEMODYNAMICS THIS SHIFT. REPLETING K/MG WITH 40MEQ KCL/2 AMPS MGSO4. TO REPEAT LYTES IN AM WITH AM LABS. RESP-PT REMAINS ON VENTILATORY SUPPORT- 30/700/10 A/C. BREATHING OVER VENT WITH INCREASED AWAKENED STATE- BREATHING IN SYNCH WITH INCREASE IN PROPOFOL GTT/SEDATION. O2 SATS- HIGH 90'S. SX Q 2-3 HOUR FOR THICK WHITISH SPUTUM. ID- AFEBRILE- REMAINS ON ANTIBX X 3- FLAGYL/VANCO/LEVO. GI- ON TUBE FEEDS- PROMOTE 30/HOUR- D/C 12 AM- NPO AFTER 12 A FOR TEE TODAY. GU- GOOD UO- 100-225/HOUR VIA FOLEY CATH. IVF- 140CC/HOUR. ATTEMPTING TO MATCH I/O. CURRENTLY I/O (+). MS/NEURO- PT AWAKE, ABLE TO SQUEEZE HAND TO COMMAND- OVERBREATHING VENT, APPEARING ANXIOUS- GIVEN BOLUS PROPOFOL, INCREASE GTT SLIGHTLY AS WELL/ CURRENTLY, SEDATED, COMFORTABLE AND BREATHING IN SYNCH WITH VENT. A/P- PT S/P LITHIUM TOXICITY/SEPSIS- CURRENTLY LESS HEMODYNAMICALLY LABILE ON LESS DOPA; AFEBRILE. CONTINUE ANTIBX FOR SEPSIS AS ORDERED. DOPA AS NEEDED FOR MAP>60, HR>50'S. CLOSELY WATCH I/O AND FLUID BALANCE- CONTINUE IVF AS ORDERED. PLAN FOR TEE- COMFORT/SEDATION WHILE INTUBATED. RESUME TUBE FEEDS ONCE TEE COMPLETE. KEEP PT AND FAMILY AWARE OF PLAN OF CARE. ||||END_OF_RECORD START_OF_RECORD=3||||19|||| Patient remains intubated and mechanically vented. vent checked and alarms functioning. Settings: A/C 700*10 30% 5 peep. BS Coarse. Please see respiratory section of carevue for further data Plan: Patient in synch with vent. Will continue to mechanically ventilate. Wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=3||||20|||| Resp Care remains ac mode 700x10x.3/5 peep. plateau 20. sxned sm to md [**First Name (Titles) 54**] [**Last Name (Titles) 55**] yellow. no weaning attempts today. refer to flow sheet. ||||END_OF_RECORD START_OF_RECORD=3||||21|||| n-appropriately arousable, sedatd with propofol infusion r-remains on ac no changes with stable oxygenation/ventilation/slight met acidosis, white sx's cv-sb 50's map's mainatained >60 with dopa at 6mcg's, new a-line plac