Synopsis and Progress
- The patient is a 65-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension, admitted to the ICU due to acute respiratory failure secondary to pneumonia.
A - The patient's airway is patent with an endotracheal tube in place, receiving mechanical ventilation.
B - The patient is on a ventilator with settings of FiO2 50%, PEEP 5 cmH2O, and tidal volume 450 mL. Oxygen saturation is maintained at 95%.
C - Blood pressure is stable at 120/80 mmHg, heart rate is 85 bpm. The patient is on norepinephrine infusion at 5 mcg/min.
D - Neurological status: GCS score is 9, the patient is sedated with propofol infusion.
E - Skin is intact with no pressure ulcers. Electrolytes show sodium 140 mmol/L, potassium 4.0 mmol/L.
F - Fluid balance is positive with 2 liters input and 1.5 liters output. Urea is 8 mmol/L, creatinine 90 µmol/L, GFR is 75 mL/min.
G - The patient is receiving enteral nutrition via a nasogastric tube. Liver function tests are within normal limits.
H - Hematological status: Hemoglobin is 12 g/dL, no transfusions required.
I - Temperature is 38.5°C, blood cultures are pending, on broad-spectrum antibiotics.
L - Central venous line and urinary catheter in place, functioning well.
FASTHUGS:
- Feeding: Enteral feeding via nasogastric tube at 60 mL/hr.
- Analgesia: Fentanyl infusion for pain management.
- Sedation: Propofol infusion for sedation.
- Thromboprophylaxis: Enoxaparin 40 mg subcutaneously daily.
- Head-up: Head of bed elevated to 30 degrees.
- Ulcer prophylaxis: Omeprazole 20 mg daily.
- Glycemic control: Insulin sliding scale for blood sugar management.
PLAN:
- Continue current ventilator settings and monitor respiratory status.
- Titrate norepinephrine to maintain MAP >65 mmHg.
- Monitor sedation levels and adjust propofol as needed.
- Continue antibiotics and reassess based on culture results.
- Maintain enteral nutrition and monitor nutritional status.
- Regularly assess skin integrity and reposition to prevent pressure ulcers.
Synopsis and Progress
- [provide a brief summary of the patient's current condition, including diagnosis, relevant history, and reason for ICU admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
A - [describe airway status, any interventions, and current management] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
B - [describe respiratory status, ventilator settings, oxygen requirements, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
C - [describe cardiovascular status, blood pressure, heart rate, medications, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
D - [describe neurological status, Glasgow Coma Scale (GCS) score, sedation, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
E - [describe skin condition, wounds, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [include lab results of electrolytes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
F - [describe fluid balance, input/output, IV fluids, lab results of urea, creatinine, GFR and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
G - [describe gastrointestinal status, nutrition, bowel movements, liver function tests, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
H - [describe hematological status, lab results, transfusions, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
I - [describe signs of infection, temperature, cultures, antibiotics, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
L - [describe lines, tubes, drains, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
FASTHUGS:
- Feeding: [describe nutritional support, enteral/parenteral feeding, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Analgesia: [describe pain management, medications, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Sedation: [describe sedation management, medications, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Thromboprophylaxis: [describe measures for preventing thrombosis, medications, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Head-up: [describe head elevation, positioning, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Ulcer prophylaxis: [describe measures for preventing ulcers, medications, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Glycemic control: [describe blood sugar management, medications, and any interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PLAN: [Describe management plan in non-numbered dot points]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
