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Progress Note 1

KEY WORDS

NOTE

46 year old man who was transferred back to the NS ICU yesterday because of sudden onset of left-sided weakness while on a regular hospital ward recovery from a recent ventriculoperitoneal shunt placement.
The patient has hydrocephalus secondary to chronic meningitis. He reports that he had a kidney transplant in 2006 (although he is only oriented to his name and place and only occasionally is correct as to today's date).
Currently he is asking a lot of questions that do not make sense but he is not complaining pain and is in no distress. In the past he has had psychiatric issues and has threatened nursing staff with violence.
Vital signs: systolic blood pressure maximum in the past 24 hrs was 180 mmHg, currently 160 mmHg. He is bradycardic with a rate of less than 60.
He is awake, alert but confused. Oriented only to his name. He is full strength in the right upper and lower extremity but on the left he has only trace arm and leg movement.
Fluids electrolytes and nutrition: He is receiving intravenous normal saline at 75 cc/hr. Sodium this morning is 144, potassium is 4.4. His urine output has been less than 30 cc/hr for the past 4 hours. His fluid intake is restricted to 1,000 cc/day. He ate 25% of his renal specialty diet this morning.
Respiratory: Breathing room air comfortably with oxygen saturation greater than 95%.
Cardiovascular: Blood pressure being controlled with labetalol and hydralazine.
Gastrointestinal: Eating. Most recent bowel movement 3 days ago.
Urinary: low volume urine output for several hours. Not currently scheduled for dialysis.
Hematology: no issues.
Infection: Receiving vancomycin. No fevers. White blood cell count is 7,000 per mmole.
Assessment: Shunted hydrocephalus with new onset dense left sided weakness of unclear etiology. Persistent confusion.
Plan:
1. MR of brain to try to determine cause of new left hemiparesis.
2. Psychiatry consultation. Continue to manage his behavior with reassurance, deferring restraints for the time being.

46岁的人谁被调回的NS加护病房因左侧突然无力昨天在一个正规的医院，最近脑室分流安置病房恢复。
病人有脑积水继发于慢性脑膜炎。他报告说，他在2006年的肾移植（尽管他只是为导向，以他的名字和地点，只偶尔是正确的，以今天的日期）。
目前，他在问一个问题，没有意义，但他没有抱怨疼痛，无痛苦，是很多。在过去他已经拥有了精神问题，并以暴力威胁，护理人员。
生命体征：收缩压在过去24小时压力最大为180毫米汞柱，目前的160毫米汞柱。他是一个不到60率心动过缓。
他是清醒，警觉而感到困惑。面向只有他的名字。他是在右上，下肢力量，但全在左边他只手臂和腿的运动跟踪。
液体电解质和营养：他正在接受75毫升/小时静脉注射生理盐水。今天上午是144钠，钾为4.4。他的尿量已为过去4个小时小于30毫升/小时。他的液体摄入量限制在1000毫升/天。他吃了他的肾专科的25％的饮食今天上午。
呼吸系统：呼吸室内空气中氧饱和度大于95％，舒适。
心血管系统：血压被控制与拉贝洛尔和肼苯哒嗪。
胃肠道：吃。 3天前最近期排便。
泌尿：低体积几个小时尿量。目前未计划在透析。
血液学：没有问题。
感染：接收万古霉素。没有发烧。白细胞计数每mmole 7,000元。
评估：新发密左不明病因脑积水分流片面的弱点。持续混乱。
计划：
1。脑议员，试图确定新左偏瘫的原因。
2。精神科咨询。继续管理他的保证行为，延迟暂时限制。

Progress Note 1

KEY WORDS
NOTE 46 year old man who was transferred back to the NS ICU yesterday because of sudden onset of left-sided weakness while on a regular hospital ward recovery from a recent ventriculoperitoneal shunt placement. The patient has hydrocephalus secondary to chronic meningitis. He reports that he had a kidney transplant in 2006 (although he is only oriented to his name and place and only occasionally is correct as to today's date). Currently he is asking a lot of questions that do not make sense but he is not complaining pain and is in no distress. In the past he has had psychiatric issues and has threatened nursing staff with violence. Vital signs: systolic blood pressure maximum in the past 24 hrs was 180 mmHg, currently 160 mmHg. He is bradycardic with a rate of less than 60. He is awake, alert but confused. Oriented only to his name. He is full strength in the right upper and lower extremity but on the left he has only trace arm and leg movement. Fluids electrolytes and nutrition: He is receiving intravenous normal saline at 75 cc/hr. Sodium this morning is 144, potassium is 4.4. His urine output has been less than 30 cc/hr for the past 4 hours. His fluid intake is restricted to 1,000 cc/day. He ate 25% of his renal specialty diet this morning. Respiratory: Breathing room air comfortably with oxygen saturation greater than 95%. Cardiovascular: Blood pressure being controlled with labetalol and hydralazine. Gastrointestinal: Eating. Most recent bowel movement 3 days ago. Urinary: low volume urine output for several hours. Not currently scheduled for dialysis. Hematology: no issues. Infection: Receiving vancomycin. No fevers. White blood cell count is 7,000 per mmole. Assessment: Shunted hydrocephalus with new onset dense left sided weakness of unclear etiology. Persistent confusion. Plan: 1. MR of brain to try to determine cause of new left hemiparesis. 2. Psychiatry consultation. Continue to manage his behavior with reassurance, deferring restraints for the time being.	46岁的人谁被调回的NS加护病房因左侧突然无力昨天在一个正规的医院，最近脑室分流安置病房恢复。病人有脑积水继发于慢性脑膜炎。他报告说，他在2006年的肾移植（尽管他只是为导向，以他的名字和地点，只偶尔是正确的，以今天的日期）。目前，他在问一个问题，没有意义，但他没有抱怨疼痛，无痛苦，是很多。在过去他已经拥有了精神问题，并以暴力威胁，护理人员。生命体征：收缩压在过去24小时压力最大为180毫米汞柱，目前的160毫米汞柱。他是一个不到60率心动过缓。他是清醒，警觉而感到困惑。面向只有他的名字。他是在右上，下肢力量，但全在左边他只手臂和腿的运动跟踪。液体电解质和营养：他正在接受75毫升/小时静脉注射生理盐水。今天上午是144钠，钾为4.4。他的尿量已为过去4个小时小于30毫升/小时。他的液体摄入量限制在1000毫升/天。他吃了他的肾专科的25％的饮食今天上午。呼吸系统：呼吸室内空气中氧饱和度大于95％，舒适。心血管系统：血压被控制与拉贝洛尔和肼苯哒嗪。胃肠道：吃。 3天前最近期排便。泌尿：低体积几个小时尿量。目前未计划在透析。血液学：没有问题。感染：接收万古霉素。没有发烧。白细胞计数每mmole 7,000元。评估：新发密左不明病因脑积水分流片面的弱点。持续混乱。计划： 1。脑议员，试图确定新左偏瘫的原因。 2。精神科咨询。继续管理他的保证行为，延迟暂时限制。