Scribe BC - Issues List

Scribe BC - Issues List **Date admitted to ICU**: 28 October 2024 **ICU day**: 4 **Past Medical History**: - Hypertension - Type 2 Diabetes Mellitus - Previous Myocardial Infarction **Current Medications**: - Metoprolol 50mg daily - Lisinopril 10mg daily - Insulin glargine 20 units at night **Procedures**: - Central line insertion - Mechanical ventilation 1. Issue, problem or request 1 (include issue, request or condition name only) - Acute Respiratory Distress Syndrome (ARDS) - [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1 (include only if applicable)] - Patient admitted with severe dyspnea and hypoxemia. Chest X-ray showed bilateral infiltrates. - [Past medical history, previous surgeries, medications, relevant to issue 1 (include only if applicable)] - PMH significant for hypertension and type 2 diabetes. Current medications include metoprolol, lisinopril, and insulin glargine. - [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 1 (include only if applicable)] - Vitals: BP 160/90, HR 110, RR 30, SpO2 88% on room air. Physical exam revealed bilateral crackles. Patient is intubated and on mechanical ventilation. - [Likely diagnosis for Issue 1 (condition name only)] - ARDS - [Differential diagnosis for Issue 1 (include only if applicable)] - Pneumonia, cardiogenic pulmonary edema - [Investigations planned for Issue 1 (include only if applicable)] - Arterial blood gas, chest CT scan - [Treatment planned for Issue 1 (include only if applicable)] - Mechanical ventilation with lung protective strategies, prone positioning, fluid management. - [Relevant referrals for Issue 1 (include only if applicable)] - None 2. Issue, problem or request 2 (include issue, request or condition name only) - Septic Shock - [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2 (include only if applicable)] - Patient developed fever and hypotension. - [Past medical history, previous surgeries, medications, relevant to issue 2 (include only if applicable)] - No relevant past medical history. - [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 2 (include only if applicable)] - Vitals: BP 70/40, HR 130, Temp 39.5°C. Physical exam revealed warm extremities and altered mental status. - [Likely diagnosis for Issue 2 (condition name only)] - Septic Shock - [Differential diagnosis for Issue 2 (include only if applicable)] - Cardiogenic shock, hypovolemic shock - [Investigations planned for Issue 2 (include only if applicable)] - Blood cultures, lactate level, complete blood count - [Treatment planned for Issue 2 (include only if applicable)] - Fluid resuscitation, vasopressors, antibiotics. - [Relevant referrals for Issue 2 (include only if applicable)] - None 3. Issue, problem or request 3, 4, 5 etc (include issue, request or condition name only) - Acute Kidney Injury - [Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc (include only if applicable)] - Patient's creatinine has increased significantly. - [Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc (include only if applicable)] - No relevant past medical history. - [Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 3, 4, 5 etc (include only if applicable)] - Urine output decreased. Creatinine 3.5 mg/dL. - [Likely diagnosis for Issue 3, 4, 5 etc (condition name only)] - Acute Kidney Injury - [Differential diagnosis for Issue 3, 4, 5 etc (include only if applicable)] - Pre-renal, intrinsic, post-renal causes - [Investigations planned for Issue 3, 4, 5 etc (include only if applicable)] - Renal ultrasound, urine analysis - [Treatment planned for Issue 3, 4, 5 etc (include only if applicable)] - Fluid management, consider renal replacement therapy. - [Relevant referrals for Issue 3, 4, 5 etc (include only if applicable)] - Nephrology consult **Critical Care**: - Patient is currently intubated and mechanically ventilated for ARDS. Receiving vasopressors for septic shock. Monitoring urine output and renal function closely. Plan to wean sedation and assess neurological status daily. "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks."