Scribe BC - ICU Consult

{ "Scribe BC - ICU Consult": { "Time seen": "14:30", "Identifying factors": "68-year-old male, male, retired teacher, transported to the hospital via EHS ambulance, referred for ICU consult by Dr. Smith.", "History of present illness": "The patient presented with severe shortness of breath and chest pain. The patient was found to have a large pulmonary embolism on CT scan. The patient was started on heparin infusion and admitted to the ICU.", "Pre-admission medical history": [ "Hypertension", "Type 2 Diabetes Mellitus", "Hyperlipidemia", "Obesity" ], "Past surgical history": [ "Appendectomy (2005)", "Right knee replacement (2018)" ], "Medications prior to admission": [ "Lisinopril 20mg daily", "Metformin 1000mg twice daily", "Atorvastatin 40mg daily", "Aspirin 81mg daily" ], "Current medications in hospital": [ "Heparin infusion", "Morphine for pain", "Oxygen via nasal cannula", "Vancomycin" ], "Allergies": "NKDA", "Social History": "Patient is married, has two adult children, and is a retired teacher. He does not smoke or use illicit drugs. Drinks alcohol socially.", "Family history": "Father had a history of coronary artery disease. Mother had hypertension.", "Code status": "Full code", "Substance use": "Patient reports occasional alcohol use, denies smoking or illicit drug use.", "Physical exam": { "General appearance/head and neck exam": "Appears in moderate distress due to shortness of breath. Temperature 37.2°C.", "CNS": "Alert and oriented to person, place, and time. Pupils are equal, round, and reactive to light. Motor strength 5/5 in all extremities. No focal neurological deficits.", "CVS": "Blood pressure 140/80 mmHg, heart rate 110 bpm, regular rhythm. JVP not elevated. Pulses 2+ in all extremities. No mottling or duskiness. Capillary refill <2 seconds. No edema. Patient is on Levo 2mcg/min iv.", "Resp": "Patient is on 4L oxygen via nasal cannula. Bilateral scattered wheezes and crackles heard on auscultation. ABGs show respiratory alkalosis.", "GI": "Abdomen soft, non-tender. Bowel sounds present. NG tube in place.", "GU": "Foley catheter in place. Urine output adequate. Fluid balance positive.", "Skin": "Skin is warm and dry. No rashes or lesions noted." }, "Labs": { "Hemoglobin": "12.5 g/dL", "White cell count": "11.2 x10^9/L", "Platelet count": "250 x10^9/L", "Sodium": "140 mmol/L", "Potassium": "4.0 mmol/L", "Bicarbonate": "28 mmol/L", "Chloride": "100 mmol/L", "Creatinine": "1.1 mg/dL", "Other labs": "PT/INR: 1.5, PTT: 60 seconds, D-dimer: 3.0 mcg/mL, Troponin: 0.1 ng/mL" }, "Previous labs": "Previous labs are within normal limits.", "Imaging": "CT scan of the chest showed a large pulmonary embolism in the right and left pulmonary arteries. Chest X-ray showed mild pulmonary edema.", "ID and micro": "Blood cultures pending. Started on Vancomycin for possible hospital acquired pneumonia.", "Active Issues": [ "Pulmonary embolism", "Acute respiratory distress", "Hypertension", "Type 2 Diabetes Mellitus" ], "Management plan": [ "Continue heparin infusion.", "Administer oxygen via nasal cannula.", "Monitor vital signs and oxygen saturation.", "Consult with cardiology.", "Continue Vancomycin for possible pneumonia." ], "Consultants": "Cardiology consulted, recommended continued anticoagulation and monitoring.", "Addendum": "Patient's condition has slightly improved with oxygen and heparin. Will continue to monitor closely.", "Critical Care": "Patient requires close monitoring of respiratory status and hemodynamic stability. Consider transfer to higher level of care if deterioration occurs." }, "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." }