神经内外科交流欢迎

US China Neuro Exchange 美中神经交流

Progress Note 3

KEY WORDS

NOTE

20 yo man with a craniopharyngioma first operated on in 2001 who has been in the Neuroscience ICU for 150 days following his most recent craniotomy for tumor resection. The main reason that he has remained in the ICU is because is sodium is very labile, sometimes he is hypernatremic, other times he is hyponatremic and he swings very rapidly.
No acute events overnight.
Vitals signs: temperature 99 (axillary), heartrate is 76, blood pressure 100/73. Respiratory rate is 16 on 21% oxygen aerosol mist with minimal secretions. There is no skin breakdown of the back or buttock. There is no lower extremity swelling. He follows simple commands but is non-verbal with a tracheostomy in place. He has been blind since he was 12 years old.
Lungs are clear to auscultation. Heart is regular with no murmurs. Abdomen is soft, nontender, and there are bowel sounds. He has a percutaneous feeding tube in place.
Fluids electrolytes and nutrition: Patient is receiving no intravenous fluids. His tube feeding formula is set at a rate of 60 cc per hour. His urine output is approximately 150 an hour. Between 6 and 7 output was 5, between 7 and 8 urine output was 225. He received subcutaneous arginine vasopressin at 10 a.m. This morning his sodium is 134. Yesterday he was 136.
Respiratory: He is breathing comfortably on his own.
Cardiovascular: He has no cardiovascular issues
GI: His most recent bowel movement was a few days
GU: He has a foley catheter in place.
Blood: no hematologic issues at this time. Hematocrit is 28 this morning. Platelets are 239.
Infection: He has been afebrile for more than 24 hours
Endocrine: He is on thryroid replacement.
Assessment: The patient is a young man with a craniopharyngioma operated twice who has sustained hypothalamic injury and has difficulty regulating his serum sodium.
Plan:
Patient will be transferred to a lower level of care facility once his sodium level is under better control. He is currently consistently following commands but not for enough time during a 24 hours period that he can participate in a rehabiliation program.

溜溜与颅咽管瘤20人于2001年首次手术谁在神经科ICU了150天之后他最近的开颅手术切除肿瘤。最主要的原因，他仍然在重症监护病房，是因为钠是非常不稳定的，有时他是hypernatremic，其他时候，他是低钠，他波动十分迅速。
没有过夜急性事件。
命脉的迹象：温度99（腋下），心率为76，血压七十三分之百。呼吸频率是21％的氧气以最小的分泌物气溶胶雾16。没有背部或臀部皮肤破裂。没有下肢肿胀。他遵循简单的命令，但不与地方气管切开术在口头上。他已经失明，因为他是12岁。
肺部听诊无杂音。心正则，无杂音。腹部柔软，无痛，有肠鸣音。他在地方经皮料管。
电解质和营养液：患者正在接受静脉输液没有。他灌食配方设定在每小时60毫升的速度。他的尿量大约是150小时。 6至7输出为5，7和8之间的尿量是225。他于上午10皮下精氨酸加压素今天早上他钠是134。昨天，他是136。
呼吸系统：呼吸舒服，他是他自己的。
心血管系统：他没有心血管问题
胃肠道：他最近的排便是数天
顾：他有一个适当的尿管。
血液：血液在这个时候没有问题。今天上午红细胞压积为28。血小板是239。
感染：他已经没有发烧超过24小时
内分泌：他已在thryroid更换。
评估：病人是一个年轻男子颅咽管瘤手术持续了两次，谁下丘脑损伤和调节有困难的血清钠。
计划：
病人将被转移到一个较低水平的医疗设施，一旦他的钠水平更好的控制之下。他目前一直在24小时以下的时间，他也可以参与复康计划，但没有足够的时间命令。

Progress Note 3

KEY WORDS
NOTE 20 yo man with a craniopharyngioma first operated on in 2001 who has been in the Neuroscience ICU for 150 days following his most recent craniotomy for tumor resection. The main reason that he has remained in the ICU is because is sodium is very labile, sometimes he is hypernatremic, other times he is hyponatremic and he swings very rapidly. No acute events overnight. Vitals signs: temperature 99 (axillary), heartrate is 76, blood pressure 100/73. Respiratory rate is 16 on 21% oxygen aerosol mist with minimal secretions. There is no skin breakdown of the back or buttock. There is no lower extremity swelling. He follows simple commands but is non-verbal with a tracheostomy in place. He has been blind since he was 12 years old. Lungs are clear to auscultation. Heart is regular with no murmurs. Abdomen is soft, nontender, and there are bowel sounds. He has a percutaneous feeding tube in place. Fluids electrolytes and nutrition: Patient is receiving no intravenous fluids. His tube feeding formula is set at a rate of 60 cc per hour. His urine output is approximately 150 an hour. Between 6 and 7 output was 5, between 7 and 8 urine output was 225. He received subcutaneous arginine vasopressin at 10 a.m. This morning his sodium is 134. Yesterday he was 136. Respiratory: He is breathing comfortably on his own. Cardiovascular: He has no cardiovascular issues GI: His most recent bowel movement was a few days GU: He has a foley catheter in place. Blood: no hematologic issues at this time. Hematocrit is 28 this morning. Platelets are 239. Infection: He has been afebrile for more than 24 hours Endocrine: He is on thryroid replacement. Assessment: The patient is a young man with a craniopharyngioma operated twice who has sustained hypothalamic injury and has difficulty regulating his serum sodium. Plan: Patient will be transferred to a lower level of care facility once his sodium level is under better control. He is currently consistently following commands but not for enough time during a 24 hours period that he can participate in a rehabiliation program.	溜溜与颅咽管瘤20人于2001年首次手术谁在神经科ICU了150天之后他最近的开颅手术切除肿瘤。最主要的原因，他仍然在重症监护病房，是因为钠是非常不稳定的，有时他是hypernatremic，其他时候，他是低钠，他波动十分迅速。没有过夜急性事件。命脉的迹象：温度99（腋下），心率为76，血压七十三分之百。呼吸频率是21％的氧气以最小的分泌物气溶胶雾16。没有背部或臀部皮肤破裂。没有下肢肿胀。他遵循简单的命令，但不与地方气管切开术在口头上。他已经失明，因为他是12岁。肺部听诊无杂音。心正则，无杂音。腹部柔软，无痛，有肠鸣音。他在地方经皮料管。电解质和营养液：患者正在接受静脉输液没有。他灌食配方设定在每小时60毫升的速度。他的尿量大约是150小时。 6至7输出为5，7和8之间的尿量是225。他于上午10皮下精氨酸加压素今天早上他钠是134。昨天，他是136。呼吸系统：呼吸舒服，他是他自己的。心血管系统：他没有心血管问题胃肠道：他最近的排便是数天顾：他有一个适当的尿管。血液：血液在这个时候没有问题。今天上午红细胞压积为28。血小板是239。感染：他已经没有发烧超过24小时内分泌：他已在thryroid更换。评估：病人是一个年轻男子颅咽管瘤手术持续了两次，谁下丘脑损伤和调节有困难的血清钠。计划：病人将被转移到一个较低水平的医疗设施，一旦他的钠水平更好的控制之下。他目前一直在24小时以下的时间，他也可以参与复康计划，但没有足够的时间命令。