Writing a Note

Your daily ICU update note can be as long or as short as you deem it to be. Time available for writing notes can be extremely short, particularly at weekends, when residents spend most of their time “putting out fires”. It is essential, however, that you enumerate the patients problems and write down a plan of care. Here follows an example of a short note.

ICU PROGRESS NOTE

9/9/02 8.15am  

Mr John Doe age 74y

Day 8 post AAA, complicated by 1. Resp Failure 2, ARF (CVVHD) 3. NSTEMI 4. Massive transfusion

Background: CABG x3 (1997), HTN (lisinopril)

Current Problems

1, Failure to wean

2. Polyuric renal failure

3. Coronary ischemia

4. Hyokalemia

5. Increased bilirubin

6. Saccral Decubitus

7. Wound dehiscence

ROS

Neuro – Ramsay 4 on midazolam 4mg/hr, morphine 2mg/hr.

Resp – FiO2 40%, PaO2 78 on PC 20 PEEP 5, rate 12. Not weaning. ABG 7.46/78/48/+2/94%, Crackles audible throughout, dull in bases. CXR – bilateral infiltrates  (ARDS)

CVS – BP 120/70, HR 92 (metoprolol 5mgq6h), CVP 8, normal HS, No murmurs, ECG T-wave iversion across anterior leads.

GI – abdomen soft, non tender, wound open but clean, post-pyeloric feed started (30ml/hr), no stool, Bilirubin has increased to 12.6, transaminases are normal.

Renal – balance -500ml (x24h), overall +ve 8l. Creatinine 2.4 (down from 2.6). Hourly outpur 80-120ml.

Endocrine – no problems

Extremities – mild ankle edema, SCDs, enoxaparin 30mgq12, large (6 x 6cm) grade 2 pressure sore over sacrum

Labs -  138/3.2/111/29   Hb 9.0 (1 unit RCC overnight), plat 230, PTR 1.5

ID -  Temp 38.2, WCC 19.2, pseudomonas in BAL x 2/7, tx cipro 200 bid, gent 350mg qd

Devices – RSCL, RRAL

Impression

ALI not resolving – infectious component, no current role for steroids. Heart rate remains a little fast in setting of ischemia – cardiology should review with regard to possible PCI. High bilirubin may be due to hemolysis (massive transfusion), cholestasis or sepsis. Renal function is returning, although K+ spillage requires vigorous supplementation (required for muscle function). Wound is healing well. Decubitus appears to be enlarging.

Plan

Neuro – DC midazolam today and assess neurologically

Resp – Trach tomorrow

CVS – increase metoprolol to 10mg q6h, cardiology to see ?PCI

GI – increase feeds to goal 75ml/h, administer PO4 enema

Renal – replace K+ losses with KPO4

Endocrine – NAD

Extremeties – wound care to see decubitus

Heme/labs – transfuse if Hb < 9, hx of CAD – continue ASA

ID – continue antibiotics x 5/7

Devices – remove central line, use peripheral veins pro temps

Michael Hunt MD  #1600

Copyright Patrick Neligan 2001-2002

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