ICU Consultant Morning Ward Round

**Intensive Care Unit :** **Date:** 1 November 2024 **Name of Patient:** John Doe **Inpatient Admitting Consultant:** Dr. Emily Carter **Inpatient Admitting Specialty:** Cardiology **Other Specialty Involvement:** Dr. Sarah Lee, Neurology Dr. Michael Brown, Infectious Diseases **Admitting Consultant:** Dr. Emily Carter **Ward Round attended by:** **ICU VMO:** Dr. Thomas Kelly **Admission Date:** 28 October 2024 **Summary:** - John Doe, 65, male - Past medical history: Hypertension, Type 2 Diabetes - Day 4 ICU - Presented with acute myocardial infarction - Current management: On ventilator support, receiving IV antibiotics - Current trajectory: Stable with gradual improvement **Past Medical History:** - Hypertension - Type 2 Diabetes **Events over Last 24 Hours:** - Maintained stable vital signs - Improved oxygenation levels - Reduced need for vasopressors **Active Conditions and Issues List:** 1. Acute Myocardial Infarction - Resulted from coronary artery blockage - History of chest pain and shortness of breath - Cardiology input: Dr. Emily Carter recommends continued monitoring and medication adjustment 2. Pneumonia - Secondary to prolonged intubation - Infectious Diseases input: Dr. Michael Brown suggests continuation of current antibiotic regimen 3. Neurological Assessment - Neurology input: Dr. Sarah Lee notes no significant changes in neurological status **Examination Findings:** **Central Nervous System** - GCS: E3, V4, M5 **Respiratory System** Ventilation Parameters: FiO2 40%, PEEP 5 cmH2O **Cardiovascular system** HR and Rhythm: Sinus rhythm BP: 120/80 mmHg **Gastro-intestinal system** Feeding Requirements: Naso-Gastric feeds initiated **Renal System** Urine output: 1500 ml/24 hours **Haematology** Hb: 12 g/dL Plats: 150 x 10^9/L **Sepsis** Temperature: 37.5°C WCC: 10 x 10^9/L **Current Antibiotics** - Ceftriaxone - Azithromycin **Microbiology** - 30 October 2024: Blood culture positive for Streptococcus pneumoniae **DVT/Ulcer Prophylaxis** - Clexane 40 mg daily - Pantoprazole 40 mg daily **Family Update:** - Dr. Thomas Kelly updated Jane Doe (wife) on 31 October 2024 about stable condition and ongoing treatment **Goals of care** Option B1 **Impression** John Doe, 65, male, with acute myocardial infarction on a background of hypertension and type 2 diabetes. Stable condition with ongoing management including ventilator support and antibiotics. **PLAN:** - Continue current ventilator settings - Monitor cardiac enzymes - Adjust medications as per cardiology recommendations **Parameters:** O2 Sats: 95% **This Clinical note has been written or checked for accuracy by** **Dr. Audra Gedmintas MBBS FCICM FACEM** **Intensive Care Specialist**