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System Based Progress Note by Dr Clardy HPI: 45 y/o female admitted with PE sp aysystolic episode. Received TPA in ER. Currently Unresponsive. Other subjectives to include nursing, and ROS from patient + pertinent systems review. VS: (Vital signs go here) GCS (list components) Vent: 100%/AC/20/500cc/peep 5 Studies : Radiology, EKG interp, ABG: 7.36/20/250/92% Telemetry strips : rhythm over last 24 hours (Better look at it if they are wearing it) F/E/N : 1/2 NS with 20 meq of KCL/Liter total volume, (don’t forget to add in enteral nutrition totals, as well as Labs : all current labs, update culture reports volumes from IV meds) Systems : at least 7 systems, general, Mental Status, Res, CV, AB, Neuro, Skin, Ext, plus any other relevant Drips : Dopamine at 15, Diprivan (diprivan has a TON of lipids) systems. Output: Foleys, NGs, Drains, GI. Balance with input (+ or -) Meds : include days on ABX, dates ABX were discontinued, other meds A/P: This includes ROS, PE, interval HPI and assessment plan for each system C onsultants : list recs but don’t go crazy. i.e. “Bronch in AM” CC A/P by Mercy ICU: Neuro/Psych: (Depression, Anxiety) · Sedated on propofol drip -- daily sedation vacation. · Continue Ativan · Pt is on Paxil and Wellbutrin. Considering her anxiety, Wellbutrin should be stopped as it can worsen agitation and anxiety. Cardiovascular: (Hypertension, Paroxysmal atrial fibrillation) · Currently controlled w/ Coreg & digoxin. Pulmonary : (COPD exacerbation, Respiratory Distress, ? HAP) · DuoNeb, Solu-Medrol 125 mg IV. Mucinex · ABx: Levaquin, Zosyn. · On mechanical ventilation GI/NUT: (Nutrition, GIB Prophylaxis) · NPO at present · GI Proph -- Renal/Electrolytes: · UOP 0.7 cc/kg/hr Infectious Disease: (HAP) · Sputum culture pending · Blood cultures (-), Influenza A/B (-), Strep Pneumonia AG (-), Cryptococcal AG (-), Hem/Coag: (Anemia, DVT Proph) · Current Hgb = · CCM recommends restrictive transfusion of 1 single unit of PRBC when hgb drops < 7 mg/dl · If there are other compelling "soft reasons" transfusion trigger is typically adjusted to < 8 mg/dl · For acute coronary ischemia or Septic Shock, < 9 mg/dl · H&H stable, transfusion not indicated · DVT Proph - LMWH/Heparin/Arixtra/SCD.
Endocrine : · Conservative glycemic control, goal < 180 mg/dl · Continue CBG q6h w/ LDSSI Musculoskeletal/Skin: · Skin without acute findings · Repositioning per ICU protocol Trauma : · None reported Family Communication: none
ER
ICU
Drugs
Electro
Medicine