Admission Note for Ventilated Patient, ICU

DATE: ............

CHIEF COMPLAINT: SOB x ........ days/months

HISTORY OF PRESENT ILLNESS:

Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -

Nausea - , Vomiting - , SOB - , Sweating - , Chest pain -
Similar SOB before -
Previous ABx therapy -
Sick contacts -

PND - , Orthopnea - , DOE -,
Heart racing -
Fever/chills - , Cough - , Ankle swelling -
Claudication - , Headache - , Blackouts -
Blurred vision - , Sore throat - , Nasal discharge -
Lightheaded - , Dizzy -
Leg/calf pain - , Recent travel -
Abdominal pain - , Black/bloody stool -
Dysuria - PPD - Flu shot this year -

ER Tx given -

PAST MEDICAL HISTORY: (circle all that apply)
MI CAD HTN DM COPD Asthma Pneumonia Prior intubations-
CHF
Catheterization -
2-D-Echo-
Stroke CA PUD PVD DVT Gallstones Renal failure
EGD Colonoscopy

PAST SURGICAL HISTORY: (circle all that apply)
CABG Cholecystectomy Hernia GSW Hysterectomy

MEDICATIONS:

ALLERGY: NKDA

FMH: (circle all that apply)
CAD DM Stroke HTN CA

SOCIAL HISTORY: (circle all that apply)
Independent NH Lives w spouse son daughter
Alcohol - no heavy occasional last drink
Smoker: no
Illicit drugs - no cocaine heroin marijuana

REVIEW OF SYSTEMS: unremarkable apart from the above symptoms

PHYSICAL EXAM:
VITALS:
SpO2 - Initial vitals -

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal

LABS:

N= L= B= AG= LFT
Creatinine clearance= , Mg++ , INR
Blood Cx:
Urine Cx: UA: Sputum Cx:
ABG:
CXR:
EKG:
Cardiac enzymes x 1 - negative , BNpep -

Old CXR:
CXR:
Old EKG:
EKG on admission:
EKG later:
Telemetry monitor:

A R A R E P Q R S T
D R I I E E

CT head:

ASSESSMENT:
- SOB due to
*Pneumonia
*Pulmonary edema
- Cardiac ischemia
*ARDS
*PE ?

- Needs intubation & ventilation
- Criteria for intubation
Hypoxemia Hypercapnea Change in mental status Protect airway Resp.muscle fatigue

Ideal body Wt =
Tidal volume 7 cc/kg =

- Pneumonia
Previous ABx Tx -  Structural lung disease -
CAP severity score (PORT score):
Antibiotics:

- Tylenol 650 mg PO q 4-6 hr PRN pain or fever
- Protonix 40 mg IV QD
- Heparin 5000 U SQ BID
- Consider means of nutrition in AM
- CBCD, CMP in AM

Signature:


Created: 02/10/2005
Updated: 03/08/2009