SOAP Note


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
· Pepcid

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 = 12
    · CCM recommends restrictive transfusion of 1 single unit of PRBC when hgb drops
    · If there are other compelling "soft reasons" transfusion trigger is typically adjusted to
    · For acute coronary ischemia
    · Septic shock
        · H&H stable, transfusion not indicated
· on Lovenox


Endocrine:
· Conservative glycemic control, goal
· Continue CBG q6h w/ LDSSI

Musculoskeletal/Skin:
· Skin without acute findings
· Repositioning per ICU protocol

Trauma:
· None reported

Family Communication: none