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Progress Note Icu

This document contains a progress note for a patient with details on their medical history, physical exam findings, test results, problems, consultants, management, and plan. The note includes information on multiple body systems and aspects of the patient's care.

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mena gerges
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
32 views

Progress Note Icu

This document contains a progress note for a patient with details on their medical history, physical exam findings, test results, problems, consultants, management, and plan. The note includes information on multiple body systems and aspects of the patient's care.

Uploaded by

mena gerges
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Progress note

Bed no: date: / / 20 day no:


Patient: Age:
HISTORY:
Medical History:
DM HTN IHD
CHEST CARDIO GIT
OTHERS virology screen
Surgical History: operation date:
Medication History:
Family History: Allergies:

Lines: CVP Ryle rectal tube ETT IV cannula urinary cath. Arterial line
Tracheostomy chest tube PEG PA cath.
C/o

Physical Exam
Neurological: level of orientation GCS:
Brain imaging:
CSF analysis:
EVD: Output over last 24 hr. Height:
Psychiatric: Toxicology screen:

Cardiovascular: HR Rhythm Bl.pr ECG


vasopressors or inotropes:
ECHO EF
Cardiac enzymes: CK/CKMB HSTROP // pro BNP

Respiratory: auscultation RR O2 sat.


Ventilator settings: mode fio2 TV RR PS PEEP PIP
Respiratory imaging:
ABG: Ph. pco2 po2 so2 Hco3 // Ph. pco2 po2 so2 Hco3

Sepsis: Temp. Max Temp Source of infection


WBCS PCT CRP
Cultures
Antibiotics

Gastrointestinal: examination: pelviabd. US


Liver function: ALT AST ALP T/D BIL Amylase Lipase

Genitourinary: Input Output: balance CVP


Urine analysis: UREA Cr.
Electrolytes: Na K Ca Mg ph. Cl
Nutrition: Type route calories albumin
IV fluids:

Hematological: HB HCT PLT // PT PTT INR D dimmer


Doppler CT plum. angio.

Endocrine: RBS HbA1c A.G // TSH fT3 fT4


Drugs:

TRUMA survey:
CPK urine color
Prophylaxis: GIT ulcer DVT
Problem list consultant Medication and management
Nutrition

IV fluids

Prophylaxis
GIT ulcer
DVT
VENTILATION
Bundle
Mouth care
Eye care
Elevation of bed
Suction
physiotherapy
Neurological

Psychiatric

Toxicology
Cardiovascular

Respiratory

Sepsis

Gastrointestinal

Genitourinary

Electrolytes

Hematological

Endocrine

TRUMA survey:
Pain management

Plan
SCORE

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