Other Epic Notes

ABG
ABGs: @BRIEFLAB(PHART,PO2ART,PCO2ART,O2HBART,FIO2ART)@
History of Platelet Inhibitor use in presence clinically sig brain bleed:
- Hold all anti-platelets
- Platelet Mapping
- Will consider platelet transfusion
Warfarin Use per Hx:
- Current INR
- Given *** Units of FFP
- Given *** Units of Vit K
- Transfuse *** Units of FFP
- Patient is a great chance of hematoma expansion.
- Low threshold to get CT Brain in any change of exam
Neurology History & Physical/Consult Note
Patient: @NAME@ Bed: @ROOMBED@
Chief Complain:
History of Presenting Illness: @NAME@ is a @AGE@ @SEX@
Past Medical History
@HXPED@
@HXPMH@
@HXPSH@
Allergies
@ALLERGY@
Family History
@FAMHX@
Social History
@SOCDOC@
Review of Systems
Neurological: The neurological system was otherwise negative except as described in the HPI/PMH.
Cardiac: Negative, except as described in the HPI/PMH.
Respiratory: Negative, except as described in the HPI/PMH.
Gastrointestinal: Negative, except as described in the HPI/PMH.
Genitourinary: Negative, except as described in the HPI/PMH.
Musculoskeletal: Negative, except as described in the HPI/PMH.
Integument: Negative, except as described in the HPI/PMH.
Hematological: Negative, except as described in the HPI/PMH.
Constitutional: Negative, except as described in the HPI/PMH.
Psychological: Negative, except as described in the HPI/PMH.
Objective:
@VS@
Exam:
General appearance: {appearance:315021::"alert, well appearing, and in no distress"}.
Mental Status:
Awake, Follows Commands
Attention: Alert
Orientation: X ***
Speech:
Fluency
Comprehension
Articulation
Repetition
Naming
Cranial Nerves:
VF: *** Pupils *** mm -> *** mm ERL, EOMI, no ptosis, nystagmus or diplopia
Facial sensation intact bilaterally; Face symmetric,
Palate symmetric Uvula and tongue midline
Motor:
Abnormal Movements: none
Bulk: normal
Tone: normal
Strength:
RUE 5/5
LUE 5/5
RLE 5/5
LLE 5/5
DTR: Symmetric, Toes Downgoing
Sensory:
Intact to Light Touch & Pin prick
Cerebellar:
FNF, HKS, RAM intact bilaterally
Romberg: ***
Gait:
***
Labs:
@RESULTRCNT(24h)@
Neuroimaging:
***
Medications:
@MED@
@MEDSSCHEDULED@
Problem List:
@PROB@
Assesment and Plan:
FEN Regular Diet
DVT Heparin 5K TID
Dispo PT/OT
SW Consult
@ME@
General Neurology Service
@NOW@
Discussed with Attending Physician Dr. ***
CC: @PCP@
LABS
CBC
@LABRCNT(WBC:3,HGB:3,HCT:3,MCV:3,PLT:3)@
BMP
@LABRCNT(CREATININE:3,BUN:3,NA:3,K:3,CL:3,CO2:3)@
ABG
@LABRCNT(PHART:3,PO2ART:3,PCO2ART:3,O2HBART:3,FIO2ART:3)@
@BRIEFLAB(PHART,PO2ART,PCO2ART,O2HBART,FIO2ART)@
LFTs
@LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI)@
COAGs
@LABRCNT(pt:3,inr:3,aptt:3)@
LIPIDs
@LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@
CARDIAC
@LABRCNT(CKTOTAL,CKMB,CKMBINDEX,TROPONINI)@
DIABETES
@LABRCNT(A1C:3,GLU,MICROALBUR,LDL,CREATININE)@
NEURO CRITICAL CARE PROGRESS NOTE
Patient: @NAME@ (DOB:@DOB@)
Room: @ROOMBED@ MRN: @MRN@
Date of admission: @ADMITDT@ No of days in hospital: @LENGTHOFSTAY@
SUBJECTIVE: @NAME@ is a @AGE@ @SEX@ had no acute events overnight.
OBJECTIVE:
@VITALSM@
@FLOWSTAT(1:24)@
@BMIE@
Exam:
General appearance: {appearance:315021::"alert, well appearing, and in no distress"}.
CV: ***
Resp: ***
GI: ***
Mental Status:
Awake, Alert, Follows Commands, Orientation X ***
Speech:
***
Cranial Nerves:
VF: *** Pupils *** mm -> *** mm ERL, EOMI, no ptosis, nystagmus or diplopia
Facial sensation intact bilaterally; Face symmetric,
Palate symmetric Uvula and tongue midline
Motor:
Abnormal Movements: none
Bulk: normal
Tone: normal
Strength:
RUE 5/5
LUE 5/5
RLE 5/5
LLE 5/5
DTR: Symmetric, Toes Downgoing
LABS
CBC
@LABRCNT(WBC:3,HGB:3,HCT:3,MCV:3,PLT:3)@
BMP
@LABRCNT(CREATININE:3,BUN:3,NA:3,K:3,CL:3,CO2:3)@
ABG
@LABRCNT(PHART:3,PO2ART:3,PCO2ART:3,O2HBART:3,FIO2ART:3)@
LFTs
@LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI)@
COAGs
@LABRCNT(pt:3,inr:3,aptt:3)@
LIPIDs
@LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@
CARDIAC
@LABRCNT(CKTOTAL,CKMB,CKMBINDEX,TROPONINI)@
DIABETES
@LABRCNT(A1C:3,GLU,MICROALBUR,LDL,CREATININE)@
INTAKE/OUTPUT
@IOBRIEF@
VENTILATION
@VENTSETTINGSLH@
CURRENT MEDICATIONS
INFUSIONS
@MEDSINFUSIONS@
SCHEDULED
@MEDSSCHEDULED@
PRN
@MEDSPRN@
NEURO-IMAGING:
***
IMPRESSION
@PROB@
ASSESSMENT AND PLAN
@PROBLEMEDITED@
@PROBLEMCARECOORD@
Discussed Patient during rounds with Dr. Cruz Attending Neuro-ICU
@ME@
Neuro-Critical Care
@NOW@
NIH Stroke Scale
Date:
Time:
1A: Level of Consciousness (0-3) :
1B: Ask Month and Age (0-3) :
1C: Follows 2 Commands (0-2) :
2: Test Horizontal Extraocular Movements (0-2) :
3: Test Visual Fields (0-3) :
4: Test Facial Palsy (0-3) :
5A: Test Left Arm Motor Drift (0-4) :
5B: Test Right Arm Motor Drift (0-4) :
6A: Test Left Leg Motor Drift (0-4) :
6B: Test Right Leg Motor Drift (0-4) :
7: Test Limb Ataxia (0-2) :
8: Test Sensation (0-2) :
9: Test Language/Aphasia
10: Test Dysarthria (0-2) :
11: Test Extinction/Inattention (0-2) :
NIHSS Total =
St. Louis University Hospital Neuro ICU Attending Daily Progress Note
Date of admission: @ADMITDT@,
No of days in hospital: @LENGTHOFSTAY@
History: @NAME@ is a @AGE@ @SEX@ who is admitted to the ICU for @CC@.
Patient currently has @PROBLEMEDITED@.
Overnight events:
-------------------------------------------------------------------------------------------------------------------Neuro
Awake/OE to voice/ gentle stimulation/ noxious stimulation/ Comatose
Alert/ agitated/
Mental Status: Regards ( ), Follow Commands ( ),
Oriented to self/location/ date/ month/ year/ situation
Language:
Cranial Nerves:
Gaze: midline/ deviated (R/L)
Pupils Equal ( ): R ( ) mm, L ( ) mm, Reactive to light ( ), EOM:Intact ( )
Corneal: R ( ), L ( ),
Face: Equal/ R UMN/ R LMN
L UMN/ L LMN
Tongue: midline/ deviated (R/L)
Cough: , Gag:
Motor: Drift: ( )
RUE: Proximal ( /5), Distal ( /5), LUE: Proximal ( /5), Distal ( /5),
Other:
EVD: Output/ 24h:
ICP: Min: Max: Mean:
HCT:
MRI:
EEG:
CSF: WBC (PMN: %), RBC: Gluc: Protein:
Xanthochromia: Y/N
NCS/EMG:
@LABRCNT(PHENYTOIN:2,PHENOBARB:2,VALPROATE:2,CBMZ:2)@
Scheduled Meds:
PRN Meds (24 h total):
Midazolam iv/po
Lorazepam iv/po
Morphine iv/im
Oxycodone po
Haloperidol iv/im
Quetiapine po
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
Cardiovascular
@FLOWSTAT(1:24)@
@IOBRIEF@
@LABRCNT(HGB:2,HCT:2,MCV:2,PLT:2)@
@LABRCNT(INR)@
@LABRCNT(PTT)@
@LABRCNT(CKMB,TROPONINI,MYOGLOBIN)@
@LABRCNT(TSH)@
@LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@
Total Fluids: ml/hr NS/ D5NS/ NS+KCL/ D5NS+KCl
NG Flushes: H2O/NS: ml q Hrs
Scheduled Meds:
PRN Meds (24 H total):
Labtetalol
Hydralazine
Exam: S1S2+, RRR ( )
EKG: {ekg findings:315101::"normal EKG, normal sinus rhythm","unchanged from previous tracings"}.
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
Pulmonary
@FLOWSTAT(9:24)@
O2 Sats: Min: Max: Mean: , EtCO2: Min: Max: Mean:
@VENTSETTINGSLH@
{SLH IP PUL O2 SUPPORT:30423216}
@LABRCNT(pHART:2,PO2ART:2,PCO2ART:2,BEART:2)@
Pulmonary Meds
Peridex:
Albuterol: schd/prn q4/q6 h
Atrovent: schd/prn q4/q6 h
Exam: Clear ( )
Secretions: Thick/thin q hrs
Oral/ Endotracheal q hrs
Chest X-ray:
Ready to wean: Yes/ No/ NA
Ready to extubate: Yes/ No/ NA
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
GI/ Metabolic
@LABRCNT(NA:2,K:2,CL:2,CO2:2,BUN:2,CREATININE:2,CALCIUM:2,MG:2,PHOS:2)@
@LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI,DBILI,ALB)@
@LABRCNT(A1C)@
Diet/ TF: Residuals:
Bedside Glucose results (over 24 h):
accuchek
Meds:
Nexium:
Reglan:
Erythromycin:
Colace/ Senna:
Docusate:
Insulin (scheduled) Units+ Insulin (PRN): Units
HOB elevated: Yes/ No
Last Bowel Movement:
Exam: soft/ firm/ tender, Bowel sounds:
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
Infection
@FLOWSTAT(6:24)@
@LABRCNT(WBC:3)@
Microbiology:
Blood:
Urine: UA (WBC: , LE -/+, Nitrite -/+),
Urine Cx:
Sputum:
CSF:
Antibiotics:
Vancomycin D 1 of
Cefepime D 1 of
Zosyn D 1 of
Antipyretics:
Tylenol: mg q4h prn/schd
Ibuprofen: 400 mg q4h prn/schd
Assessment/ Plan:
-------------------------------------------------------------------------------------------------------------------
Skin:
Intact/ abrasion/ laceration/ other skin findings ( )
Meds:
Xenaderm
Nystatin
Assessment/ Plan:
-------------------------------------------------------------------------------------------------------------------
Lines:
Multilumen CVL D1 , site: R/L IJ, R/L SCL, R/L femoral
PICC: R/ L D1
A-line: R/L Radial/Femoral/Brachial/Axillary
PIV:
Assessment/ Plan:
Continues to need central access
Assess for peripheral access
Still needs arterial access
D/C CVL
D/C A line
-------------------------------------------------------------------------------------------------------------------
DVT Prophylaixs
R/L TED
R/L SCD
SC Heparin
Lovenox:
Heparin infusion , rxed
IVC filter: , rxed on
Last venous doppler: -ve/ thrombosis in on
Assessment/ Plan:
-------------------------------------------------------------------------------------------------------------------
CURRENT MEDICATIONS
INFUSIONS
@MEDSINFUSIONS@
SCHEDULED
@MEDSSCHEDULED@
PRN
@MEDSPRN@
-------------------------------------------------------------------------------------------------------------------
Event Management:
I have been monitoring and supervising management of this patient who is critically ill, unstable and at high risk of deterioration/ organ failure related to:
Cerebral Edema
Vasospasm
Hydrocephalus
Herniation/
Status Epilepticus
Electrolyte disturbance
Cardiac arrhythmia
Respiratory failure
Patient continues to require osmotic therapy etc....
35/75/ mins of critical care services provided throughout the day (time does not include procedures) including
Serial assessment of neurologic/cardiovascular/ respiratory status
Review management plan with ICU team, bedside nurse and primary team
Review of multiple databases and radiology images in ICU
Documentation
Neuro ICU Attending: @ME@
St. Louis University Hospital Neuro ICU Attending Note
Date of admission: @ADMITDT@,
No of days in hospital: @LENGTHOFSTAY@
History: @NAME@ is a @AGE@ {handedness:20494} @SEX@ who is admitted to the ICU for @CC@. Patient arrived from OSH/ ED after transferred from home/ nursing home/ for @CC@ In ED, patient's vital signs were BP= , HR= , RR= , O2 sat= . Exam in ED was significant for .CT/MRI head / EEG in ED showed . Patient received interventions in ED ........ Subsequently he was transferred to ICU.
Since arrival to ICU patient has been
Past Medical Hx: @MEDICALHX@
Home Medication: @HMEDS@
Allergy: @ALLERGY@
Social Hx: @SOCHXP@
Family Hx: @HXFAMILY@
-------------------------------------------------------------------------------------------------------------------Neuro
Awake/OE to voice/ gentle stimulation/ noxious stimulation/ Comatose
Alert/ agitated/
Mental Status: Regards ( ), Follow Commands ( ),
Oriented to self/location/ date/ month/ year/ situation
Language:
Cranial Nerves:
Gaze: midline/ deviated (R/L)
Pupils Equal ( ): R ( ) mm, L ( ) mm, Reactive to light ( ), EOM:Intact ( )
Corneal: R ( ), L ( ),
Face: Equal/ R UMN/ R LMN
L UMN/ L LMN
Tongue: midline/ deviated (R/L)
Cough: , Gag:
Motor: Drift: ( )
RUE: Proximal ( /5), Distal ( /5), LUE: Proximal ( /5), Distal ( /5),
Other:
EVD: Output/ 24h:
ICP: Min: Max: Mean:
HCT:
MRI:
EEG:
CSF: WBC (PMN: %), RBC: Gluc: Protein:
Xanthochromia: Y/N
NCS/EMG:
@LABRCNT(PHENYTOIN:2,PHENOBARB:2,VALPROATE:2,CBMZ:2)@
Scheduled Meds:
PRN Meds (24 h total):
Midazolam iv/po
Lorazepam iv/po
Morphine iv/im
Oxycodone po
Haloperidol iv/im
Quetiapine po
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
Cardiovascular
@FLOWSTAT(1:24)@
@IOBRIEF@
@LABRCNT(HGB:2,HCT:2,MCV:2,PLT:2)@
@LABRCNT(INR)@
@LABRCNT(PTT)@
@LABRCNT(CKMB,TROPONINI,MYOGLOBIN)@
@LABRCNT(TSH)@
@LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@
Total Fluids: ml/hr NS/ D5NS/ NS+KCL/ D5NS+KCl
NG Flushes: H2O/NS: ml q Hrs
Scheduled Meds:
PRN Meds (24 H total):
Labtetalol
Hydralazine
Exam: S1S2+, RRR ( )
EKG: {ekg findings:315101::"normal EKG, normal sinus rhythm","unchanged from previous tracings"}.
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
Pulmonary
@FLOWSTAT(9:24)@
O2 Sats: Min: Max: Mean: , EtCO2: Min: Max: Mean:
@VENTSETTINGSLH@
{SLH IP PUL O2 SUPPORT:30423216}
@LABRCNT(pHART:2,PO2ART:2,PCO2ART:2,BEART:2)@
Pulmonary Meds
Peridex:
Albuterol: schd/prn q4/q6 h
Atrovent: schd/prn q4/q6 h
Exam: Clear ( )
Secretions: Thick/thin q hrs
Oral/ Endotracheal q hrs
Chest X-ray:
Ready to wean: Yes/ No/ NA
Ready to extubate: Yes/ No/ NA
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
GI/ Metabolic
@LABRCNT(NA:2,K:2,CL:2,CO2:2,BUN:2,CREATININE:2,CALCIUM:2,MG:2,PHOS:2)@
@LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI,DBILI,ALB)@
@LABRCNT(A1C)@
Diet/ TF: Residuals:
Bedside Glucose results (over 24 h):
accuchek
Meds:
Nexium:
Reglan:
Erythromycin:
Colace/ Senna:
Docusate:
Insulin (scheduled) Units+ Insulin (PRN): Units
HOB elevated: Yes/ No
Last Bowel Movement:
Exam: soft/ firm/ tender, Bowel sounds:
Assessment / Plan:
-------------------------------------------------------------------------------------------------------------------
Infection
@FLOWSTAT(6:24)@
@LABRCNT(WBC:3)@
Microbiology:
Blood:
Urine: UA (WBC: , LE -/+, Nitrite -/+),
Urine Cx:
Sputum:
CSF:
Antibiotics:
Vancomycin D 1 of
Cefepime D 1 of
Zosyn D 1 of
Antipyretics:
Tylenol: mg q4h prn/schd
Ibuprofen: 400 mg q4h prn/schd
Assessment/ Plan:
-------------------------------------------------------------------------------------------------------------------
Skin:
Intact/ abrasion/ laceration/ other skin findings ( )
Meds:
Xenaderm
Nystatin
Assessment/ Plan:
-------------------------------------------------------------------------------------------------------------------
Lines:
Multilumen CVL D1 , site: R/L IJ, R/L SCL, R/L femoral
PICC: R/ L D1
A-line: R/L Radial/Femoral/Brachial/Axillary
PIV:
Assessment/ Plan:
Continues to need central access
Assess for peripheral access
Still needs arterial access
D/C CVL
D/C A line
-------------------------------------------------------------------------------------------------------------------
DVT Prophylaixs
R/L TED
R/L SCD
SC Heparin
Lovenox:
Heparin infusion , rxed
IVC filter: , rxed on
Last venous doppler: -ve/ thrombosis in on
Assessment/ Plan:
-------------------------------------------------------------------------------------------------------------------
CURRENT MEDICATIONS
INFUSIONS
@MEDSINFUSIONS@
SCHEDULED
@MEDSSCHEDULED@
PRN
@MEDSPRN@
-------------------------------------------------------------------------------------------------------------------
Event Management:
I have been monitoring and supervising management of this patient who is critically ill, unstable and at high risk of deterioration/ organ failure related to:
Cerebral Edema
Vasospasm
Hydrocephalus
Herniation/
Status Epilepticus
Electrolyte disturbance
Cardiac arrhythmia
Respiratory failure
Patient continues to require osmotic therapy etc....
35/75/ mins of critical care services provided throughout the day (time does not include procedures) including
Serial assessment of neurologic/cardiovascular/ respiratory status
Review management plan with ICU team, bedside nurse and primary team
Review of multiple databases and radiology images in ICU
Documentation
Neuro ICU Attending: @ME@
Initial Ventilator Settings:
Mode: AC
Resp Rate: 14
Tidal Volume: 600
Peep: 5
Fio2: 100%
Assesment and Plan:
**Symptom - **Localization - **Vascular Teritory Vs Cause (Aneurysm Vs HTN)
Hemorrhagic Stroke:
- Admit to ICU (Vitals Q1)
- Telemetry
- BP Monitoring
- Neuro Checks Q1 Hour for 4 Hours -> Q2 Hours for 4 Hours -> Q4 hours for 24 hours.
- Keep SBP<160 and DBP <100
(Use Hydralazine 10 mg, Labetolol 10 mg IV Q30 mins
(May Start Nicardipine Gtt 5mg/hr max dose 15mg/hr)
- Repeat CT Scan after 24 Hours
(If no expansion in Hemorrahge on repeart CT may move to floor)
- CTA Head and Neck for vascular abnomality and aneurysm
- ESR, CRP, HbA1c, Lipid Panel, UA, UDS
- Cardiac Echo
- Avoid Sub-Q Heparin (DVT Prophylaxis) for 48 Hours
- If Acute Change in Mental Status; STAT CT Brain
Other Comfort Measures PRN Orders:
- Pain
Mild - Tylenol 650mg PO Q6 Hours
Mod - Percocet 5/325 mg PO Q9 hours
Severe - Fentanyl 15mcg IV Q2 Hours
- Nausea and Vomiting
Mild/Mod - Reglan 10 mg IV Q12 Hours
Severe - Zofran 4 mg IV Q 6 Hours
- Shortness of Breath
Albuterol 2.5 mg INH Q 6hours
Ibratropium 0.5 mg INH Q 6hours
- Constipation
Docusate 100 mg PO TID
Senna 8.6 mg PO BID
Miralax 17gm PO BID
**Cerebral Vasospasm Prophylaxis:(if SAH)
- Nimodipine 60 mg every 4 hours for 21 days
- Modified Fisher Scale = 1
**Seizure Prophylaxis:(if Cortical)
- Keppra 500 mg PO BID for 7 Days
FEN
- Bedside Swallow Eval
DVT Prophylaxis
- Hold SubQ Heparin for 48 Hours then
- Heparin 5000mg SQ BID
- SCDs