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)
Studies
: Radiology, EKG interp,
Telemetry strips
: rhythm over last 24 hours (Better look at it if they are wearing it)
Labs
: all current labs, update culture reports
Systems: at least 7 systems, general, Mental Status, Res, CV, AB, Neuro, Skin, Ext, plus any other relevant systems.
 
Vent: 100%/AC/20/500cc/peep 5
ABG: 7.36/20/250/92%
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 volumes from IV meds)
Drips
: Dopamine at 15, Diprivan (diprivan has a TON of lipids)
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
Consultants: 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