Notes for both DOS
This note was coded 99233:
Impression:
-
Vent Dependent Resp Failure - DAY # 6
CAP - Left lower lobe
Bilateral cavitary lesions in the upper lobe
Hypotension requiring pressors
cirrhosis
Thrombocytopenia
Dehydration
Hyponatremia
Anemia
Malnutrition
Oral candidiasis
Deconditioning
H/O LUNG CANCER POST LUL LOBECTOMY
Plan:
-
vent management per pulmonary
antibiotics per ID
Code level 3 - treat hypotension and arrhythmias
Family meeting 8/5/09 - with no plans for trach
DC TPN - TFs are at goal rate
Note:
-
Pt remains in the ICU on the Vent
Sedated
TPN and TFs cont
Chart reviewed
Case was discussed with multiple consultants
Presently hypotensive - pressors to be restarted.
Case was discussed with POA by pulmonary
Family is OK with treating hypotension and arrhythmias
Plt count is low - but stable
Aristra was started 8/2/09
Vital Signs
Date Time Temp Pulse Resp B/P Pulse Ox O2 Delivery FiO2
8/3/09 06:00 112
8/3/09 06:00 25 96/75 99 Mechanical Ventilator 30
8/3/09 04:00 98.0
Lungs: scattered ronchi and wheezes
Heart: RSR
EXt: thin, no edema
Multivitamins 10 35 mls/hr 8/3/09 0015
ml/Chromium/ Q24H/IV 8/3/09 0400
Copper/Manganese/
Zinc 1 ml/
Parenteral
Electrolytes 20
ml/Potassium
Phosphate 15 mm/
Potassium
Chloride 20 meq/
Magnesium Sulfate
12 meq/Calcium
Gluconate 4.65
meq/Sodium
Acetate 15 meq/
Potassium Acetate
10 meq/Thiamine
HCl 50 mg/Amino
Acids/Dextrose
Feeding Tube Type Dobhoff 8/3/09 0400
Tube Feeding/Supplement Type Jevity 1 8/3/09 0400
Tube Feeding Rate 45 ml/hr 8/3/09 0400
Pre-admission Medications:
-
Spironolactone 100 mg daily.
prednisone 10 mg daily.
Flomax 0.4 mg daily.
Darvon one tablet q.4h p.r.n. for pain.
This note from previous day was coded 99291:
Plan
-
1) Vent Dependent Resp Failure--Remains intubated. CXR pending--may need bronch if worsening or if no improvement. Per family, continue vent, but Level 3 code if status worsens.
2) Cavitary Pneumonia and TB--Cont meds per pulm and ID. AFB PCR pending. HIV resent--pending. Pt with temp 100.0 overnight--will d/w pulm and ID if diagnostic thoracentesis would be of any benefit.
3)Cardiac--Hypotension and CHF--Contuinue careful fluid balance. Cardiology and pulm following. Off pressors at present, though pressures lower today than yesterday.
4)Neuro--Neuro following--likely sx due to hypoxia episode and low perfusion. Weaker on Right side. Made eye contact and making purposeful movements this AM when diprovan off.
5)Thrombocytopenia--Check HIT panel. For now continue Lovenox.
6)Anemia-Now at 9.1. Monitor closely.
7) Malnutrition--Continue doboff feeding and trying to wean off tpn
8)Deconditioning
9)DVT proph
Impression
Vent Dependent Resp Failure
Left lower lobe community acquired pneumonia
Bilateral cavitary lesions in the upper lobe
Hypotension requiring pressors
Thrombocytopenia
Dehydration
Hyponatremia
Anemia
Malnutrition
Oral candidiasis
Deconditioning
Subjective
-
Pt remains on vent. When Diprovan off this AM, making eye contact. When nurse said good morning, he mouthed "morning" in response. Family meeting with 3 daughters 2 days ago--agree to Level 3 code status, but continue current level of care.
Physical Examination
General Appearance: Sedated on vent.
Cardiovascular: Normal S1/S2
Lungs: +Coarse BS. Decreased at Left base.
Abdomen: Soft, Non-Tender, + Bowel Sounds
Neuro: Sedated
Extremities: No Calf Tenderness, + Edema with mild weeping upper extrem's, No LE edema