ICU daily note

1 November 2024 Patient seen by Dr. Tom Kol, Anaesthetist John Doe, 45 years old, 5 days in ICU. Diagnosis: Acute Respiratory Distress Syndrome (ARDS) due to pneumonia. Background history: Type 2 Diabetes Mellitus, Hypertension. Current issues list: - Respiratory failure requiring mechanical ventilation. - Hemodynamic instability. Progress since admission list: - Improved oxygenation with reduced FiO2 requirements. - Stabilized blood pressure with reduced vasopressor support. Resuscitation status: Full code. Examination: Airway: Intubated Breathing: - Chest Auscultation: Bilateral crackles - Ventilation Mode: SIMV, FiO2 40%, PS 10, PEEP 5 - ABG: pH 7.35, Po2 85, Pco2 45, Hco3 24 - Chest X-ray: Bilateral infiltrates Circulation: - CRT: <2 seconds, MAP: 70 mmHg, BP: 110/70 mmHg, HR: 90 bpm, Lactate: 1.5 mmol/L - Peripheral pulses: Present, no edema - Inotrope: Noradrenaline 0.05 mcg/kg/min - Fluid balance: Positive 500 ml - Echo: Normal LV function CNS: - Sedation: Propofol 50 mg/hr - RASS Score: -2 - Delirium: None - Pupils: Equal and reactive - Moving all limbs to painful stimulus - CT brain: No acute changes GIT: - Abdomen: Soft, non-tender - Bowel sounds: Present - NG feed: Tolerating well - Last bowel motion: 31 October 2024 - Liver function tests: Normal - Blood glucose levels: 8 mmol/L Haematology: - Hb: 12 g/dL, Platelet: 150 x10^9/L, INR: 1.1, APTT: 30 seconds - Anti coagulants: Enoxaparin 40 mg daily Renal: - Sodium: 140 mmol/L, Potassium: 4.0 mmol/L, Urea: 6 mmol/L, Creatinine: 80 µmol/L - Urine output: 1500 ml/24 hrs Sepsis: - WCC: 12 x10^9/L, CRP: 50 mg/L - Blood cultures: Negative - Antibiotics: Meropenem, 3 days Peripheries: No infection suspected. Pressure sores: None Mobility: Bedbound Plan: - Continue to ventilate, target Po2 > 80 mmHg - Wean vasopressors - Wean sedation, target RASS 0 - Laxatives to ensure bowel movement - Maintain fluid balance - Review drug cardex - Physiotherapy and mobilisation Dr. Tom Kol