Scribe BC - ICU Ward Round Note (ABCDEFGHIL Assessment)

Scribe BC - ICU Ward Round Note (ABCDEFGHIL Assessment) Synopsis and Progress - The patient, [insert age] year old male, was admitted to the ICU on 28 October 2024 due to severe sepsis secondary to community-acquired pneumonia. He has a history of hypertension and type 2 diabetes. He initially presented with fever, cough, and shortness of breath. He required intubation and mechanical ventilation upon arrival. A - Airway is secured with an endotracheal tube, size 8.0, at 22cm at the lip. The patient is tolerating the tube well. No signs of obstruction. Suctioned clear secretions. B - Respiratory status: Ventilator settings: Assist Control, FiO2 40%, PEEP 5 cm H2O, RR 16, Vt 450ml. Oxygen saturation is 96%. Bilateral equal air entry. Chest X-ray shows improving consolidation in the right lower lobe. Arterial blood gas (ABG) shows pH 7.38, PaCO2 42 mmHg, PaO2 88 mmHg, HCO3 24 mEq/L. C - Cardiovascular status: Blood pressure 120/70 mmHg, heart rate 88 bpm, regular rhythm. Patient is on norepinephrine 0.1 mcg/kg/min for blood pressure support. No new arrhythmias. Cardiac output is stable. No signs of ischemia. D - Neurological status: Glasgow Coma Scale (GCS) score is 15. Patient is awake, alert, and oriented. Sedation weaned off. Pupils equal and reactive to light. No focal neurological deficits. E - Skin condition: Skin is intact. No signs of pressure ulcers. IV site on the left arm is clean and dry. Electrolytes: Sodium 138 mEq/L, Potassium 4.0 mEq/L, Chloride 102 mEq/L, Bicarbonate 24 mEq/L. F - Fluid balance: Input: 2000ml IV fluids, 500ml enteral feeds. Output: 1000ml urine, 200ml from drains. Net positive fluid balance. Urea 35 mg/dL, Creatinine 1.2 mg/dL, GFR 65 mL/min/1.73m². G - Gastrointestinal status: Bowel sounds present. Tolerating enteral feeds at 50ml/hr. No abdominal distension. Liver function tests are within normal limits. H - Hematological status: Hemoglobin 10.5 g/dL. Platelets 180 x 10^9/L. White blood cell count 12 x 10^9/L. No active bleeding. No transfusions required. I - Signs of infection: Temperature 37.8°C. Blood cultures pending. Sputum culture pending. Started on broad-spectrum antibiotics (meropenem and vancomycin). L - Lines, tubes, drains: Central venous catheter in right internal jugular vein. Arterial line in the left radial artery. Foley catheter in place. Chest tube on the right side draining minimal serous fluid. FASTHUGS: - Feeding: Enteral feeds at 50ml/hr via nasogastric tube. - Analgesia: Patient is receiving paracetamol 1g IV every 6 hours. - Sedation: Sedation weaned off. - Thromboprophylaxis: Enoxaparin 40mg subcutaneously daily. - Head-up: Head of bed elevated to 30 degrees. - Ulcer prophylaxis: Pantoprazole 40mg IV daily. - Glycemic control: Blood glucose monitoring every 4 hours. Insulin sliding scale as needed. PLAN: - Continue antibiotics and monitor cultures. - Wean ventilator settings as tolerated. - Monitor fluid balance and electrolytes. - Continue enteral feeds and advance as tolerated. - Monitor neurological status. - Daily chest X-ray. "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."