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Patient was admitted to the neurosurgery service and underwent an emergent R craniotomy with drainage of his subdural hemorrhage. Postoperatively he was transferred to the intensive care unit extubated and stable. He was maintained on dilantin for seizure prophylaxis, his blood pressure was controlled and he was monito...
There remains some low attenuation right subdural fluid. There remains subfalcine herniation. nsr w/ rare pac noted.resp: lungs clear. subtherapeutic dilantin level this am. The leftward shift of the septum pellucidum, measured at the same location, has decreased from 1.3 cm to 0.8 cm. Superficial to that, underlying ...
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[ { "category": "Nursing/other", "chartdate": "2170-06-17 00:00:00.000", "description": "Report", "row_id": 1516710, "text": "Pt to SICU-R sided SDH, one week history of ataxia, states he may have hit his head on the \"bulk head\", c/o of H/A and took asa, to OSH where CT showed right subdural hem...
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38 y/o female with history of autoimmune diseases (Crohn's vasculitis, psoriasis) with autoimmune hemolytic anemia following fever. . 1. Autoimmune Hemolytic Anemia: Etiology includes acquired post infectious autoimmune process, reactive autoimmune process after tappering steroids. Presented febrile. WBC was elevated i...
Sinus arrhythmiaSince previous tracing of , the heart rate has decreased
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[ { "category": "ECG", "chartdate": "2151-03-22 00:00:00.000", "description": "Report", "row_id": 268032, "text": "Sinus arrhythmia\nSince previous tracing of , the heart rate has decreased\n\n" }, { "category": "ECG", "chartdate": "2151-03-21 00:00:00.000", "description": "Report"...
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The patient was admitted to the Trauma Team for observation. Secondary to patient's age and multiple rib fractures with associated morbidity, the Anesthesia Department was consulted to perform epidural anesthesia on the patient to aid in the aggressive pulmonary toilet. The patient declined this. The patient was tre...
NEEDS ENCOURAGEMENT FOR FLD INTAKE.GU: VOIDING CLEAR YELLOW ON BEDPAN QS.ID: AFEBRILEA/ HD STABLE. GIVEN FENT 50MCG X2 AND VIOXX WITH EFFECT. )Renal- adequate u/o per foley..clear/yellowResp- 4L nc with rr mid teens to 21 in nonlabored breathing pattern breath sounds are clear with diminished coarse sounds at LLL....
5
[ { "category": "Nursing/other", "chartdate": "2200-11-14 00:00:00.000", "description": "Report", "row_id": 1556642, "text": "PT IS A Y/O FEMALE ADM TODAY AFTER FALL AT HOME IN BR. PT SUSTAINED LT RIB FX'S AND L1-2 TRANSVERSE PROCESS FXS.\nPMH: CAD, PVD, CEREBELLAR CVA, HTN, ULCERATIVE COLITIS, M...
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"62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic low back pain, anemia, GERD, a(...TRUNCATED)
"Q2-3 hrs;no desating,gets resp distress that easily clears with suction ,cxr more pul edema pi(...TRUNCATED)
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[{"category":"Nursing","chartdate":"2103-03-04 00:00:00.000","description":"Nursing Progress Note","(...TRUNCATED)
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"The patient developed a moderate to large circumferential pericardial effusion, for which he underw(...TRUNCATED)
"Thereis brief right atrial diastolic invagination.IMPRESSIOn: Moderate to large pericardial effusio(...TRUNCATED)
11
[{"category":"Radiology","chartdate":"2156-06-15 00:00:00.000","description":"CT ABDOMEN W/O CONTRAS(...TRUNCATED)
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"56 year old male with a past medical history of cerebral atriaovenous malformation (AVM) staus post(...TRUNCATED)
"Extensive vasogenic edema involving right hemisphere is unchanged since prior with extensive mass e(...TRUNCATED)
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[{"category":"Radiology","chartdate":"2165-07-14 00:00:00.000","description":"CT ABD & PELVIS WITH C(...TRUNCATED)
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"(By issue) 1. Right lower extremity cellulitis and ulcerations - The patient was admitted to the (...TRUNCATED)
"HO aware.RESP: B/L BS diminished. BS hypoactive. Tol clears.Endo: BS 177, 193. BLE edema. Mg+ 1.7, (...TRUNCATED)
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[{"category":"Radiology","chartdate":"2190-03-12 00:00:00.000","description":"CATH INFUSN,PER/CENT/M(...TRUNCATED)
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"78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who present(...TRUNCATED)
"On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic ve(...TRUNCATED)
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[{"category":"Physician ","chartdate":"2145-03-04 00:00:00.000","description":"Attending Note","row_(...TRUNCATED)
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"Patient is a 45 y/o female with CAD s/p CABG, diastolic HF and kidney transplant presenting from OS(...TRUNCATED)
"CARDIAC CATH: 1. CARDIAC CATH: 1. To IR, R brachial single lumen PICC placed. FS at 22:00- 32 s(...TRUNCATED)
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[{"category":"Echo","chartdate":"2148-09-25 00:00:00.000","description":"Report","row_id":63629,"tex(...TRUNCATED)
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"This 57-year-old patient with recent syncopal attacks was investigated and was found to have a crit(...TRUNCATED)
"Mild (1+) aorticregurgitation is seen. Normal ascending aortadiameter. A right-sided PICC line is a(...TRUNCATED)
13
[{"category":"Radiology","chartdate":"2144-02-07 00:00:00.000","description":"CHEST (PORTABLE AP)","(...TRUNCATED)
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