JSK - NCC Note

Patient: @NAME@ Bed: @ROOMBED@ Length of Stay: @RRHLOS@

Neurocritical Care/Stroke

CC: *** Primary Diagnosis: *** HPI Summary: ***

Subjective, Overnight events and Hospital Course *** - ***

Summary Exam: @TMAX(24)@*** - ***

Assessment and Plan/Decision Making: Neurological: ***

  • Neurochecks Q***Hr Day shift and Q***Hr night shift Goals: Na goal 135 - 145 BP goal MAP > 65 and SBP < *** Pain Minimize pain meds PT/OT/ST Initiated DVT Prophylaxis {jskdvt:156792} Cardiovascular: Hypertension (Present on admission)
    • SBP < ***
    • PRNs ordered Renal: No active issues Respiratory No active issues GI/Endo Hyperglycemia (Present on admission)
    • SSI Hematology No active issues Infectious No active issues Skin *** Lines *** PIVs Only Disposition {jskdispo:156790} GoalsofCare *** Code Status @RRCODESTATUS@

This patient is critically ill due to acute impairment of the multiple system as a result of *** with high probability of imminent or life threatening deterioration in the patient’s condition that requires ICU management.

The care that I provided includes detailed clinical assessment, interpretation of multiple physiological parameters, high complexity decision making to assess, manipulate, and support vital system function to treat multi system failure and to prevent further life threatening deterioration of the patient's condition.

I provided *** minutes of Critical Care to this patient. This included review of recent events, clinical examination and review of data on multiple occasions, management of multiple organ systems, and discussion about treatment with the members of the multidisciplinary ICU team and documentation. This time does not include time spent in performing any separately billed procedures.

@JSKME@

HPI Per Dr. *** on *** : "@NAME@ is a @AGE@ year-old @SEX@ with ***

Denies chest pain, abdominal pain, Nausea and vomiting."

=====================

COMPREHENSIVE PHYSICAL EXAM:

VITALS: Vitals with min/max:

Vital Last Value 24 Hour Range Temperature @FLOWINST(6::1)@ @FLOWSTAT(6:24::1)@ Pulse @FLOWINST(8::1)@ @FLOWSTAT(8:24::1)@ Respiratory @FLOWINST(9::1)@ @FLOWSTAT(9:24::1)@ Non-Invasive Blood Pressure @FLOWINST(5::1)@ @FLOWSTAT(5:24::1)@ Pulse Oximetry @FLOWINST(10::1)@ @FLOWSTAT(10:24::1)@ Arterial Blood Pressure @FLOWINST(301260::1)@ @FLOWSTAT(301260:24::1)@

GENERAL:  ***No apparent distress

EYES:  ***No ptosis, clear conjunctivae.  Pupil exam as in NEURO exam below

PSYCHIATRIC:
	Level of Sensorium — {conscience:123102}
	Orientation -- x {NUMBERS 0-4:108966}
NEUROLOGICAL:
	Language {jsklang:157530}
	Dysarthria {Dysarthria:155248}
	CN -- PERRLA, EOMI, Facial Droop ***
	Motor Strength -- 
	LUE {NEURO RATING SCALE 5:119244} RUE {NEURO RATING SCALE 5:119244}
	LLE {NEURO RATING SCALE 5:119244}  RLE {NEURO RATING SCALE 5:119244}
	Motor Tone -- No cogwheel ridigity

MUSCULOSKELETAL:  Motor strength & tone as in NEURO exam above
	
CARDIOVASCULAR:
	Peripheral Pulses -- ***Dorsalis pedis & posterior tibialis pulses 2+ bilaterally
	Auscultation -- ***RRR.  Normal S1 S2.  No murmur
RESPIRATORY:
	Effort -- *** Normal
	Auscultation -- ***Breath sounds clear and symmetric

ABDOMEN: 
	Palpation -- ***No tenderness or masses.  No organomegaly
	Auscultation -- *** Normal bowel sounds

SKIN:  
	Inspection --  ***No masses or lesions by inspection
	Palpation --   ***No masses or lesions by palpation

======================

Review of Systems

ROS: {jskros:157529}

======================

Historical Data reviewed:

PAST MEDICAL HISTORY: @MEDICALHX@ @SURGICALHX@

FAMILY HISTORY: @FAMHX@

SOCIAL HISTORY: @SOCH@

ALLERGIES: @ALLERGY@

======================

Data in the EMR was reviewed either in multidisciplinary rounds or separately. All images were personally reviewed. Pertinent data as follows

----------Neuro----------

GSC @FLOWINST(2599::1)@ LOC @FLOW(5550000028)@ Eye @FLOWINST(2600::1)@ Verbal @FLOWINST(2602::1)@ CT: @LASTIMGIMP(img1001)@ CTA Head/Neck: @LASTIMGIMP(img1061)@ MRI: @LASTIMGIMP(img2006)@ MRA Head/Neck @LASTIMGIMP(img2127)@ @LASTIMGIMP(img2125)@

----------Cardiovascular----------

Cuff BP @FLOW(5::1)@ @FLOWSTAT(5:24::1)@ Art BP @FLOW(301260::1)@ @FLOWSTAT(301260:24::1)@ Coags @LABRCNT(pt:3,inr:3,aptt:3)@ Toponins @LABRCNT(TROPONINI:3)@ @LABRCNT(CKTOTAL,CKMB,CKMBINDEX)@ Thyroid @LABRCNT(TSH)@ Lipids @LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@ ECHO: @LASTPROC(ECHO101)@ EKG: @LASTPROC(ECG1)@

----------Renal----------

@IOBRIEF@ @LABRCNT(sodium:3,potassium:3,chloride:3,co2:3,glucose:3;aniongap:3,phos:3,mg:3)@ @LABRCNT(BUN:3,CREATININE:3)@ @LABRCNT(lacta:3)@

----------Pulmonary----------

Respiratory Rate @FLOW(9::1)@ @FLOWSTAT(9:24::1)@ SpO2 (@FLOW(250026::1)@) @FLOW(10::1)@ @FLOWSTAT(10:24::1)@

@LABRCNTIP(APH:3,APCO2:3,APO2:3,ASAT:3,AHCO3:3,FIO2:3)@

@VENTSETTINGS@ RT Assessments: Sputum @FLOW(302600)@, @FLOW(302610)@, @LASTIMG(img026:1)@

----------GI----------

LFTs @LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI)@ @LABRCNT(A1C)@

----------Infectious ----------

@FLOWSTAT(6:24)@ @LABRCNT(WBC:3,HGB:3,HCT:3,MCV:3,PLT:3)@ @LABRCNTIP(RESR:3,CRP:3,AST:3,GPT:3)@ @LABRCNTIP(creatinine:3,PCT:3,LACTA:3, VANCT:3)@ @LABRCNTIP(usp2g:3,uph:3,urob:3,uwbc:3,ubactr:3,unitr:3,LEUK:3,urbc:3,uwbc:3)@ Microbiology: @LASTLABX(SDES:4)@ @LASTLABX(CULT:4)@

----------Medication Reivew----------

CURRENT MEDICATIONS

INFUSIONS @MEDSINFUSIONS@

SCHEDULED @MEDSSCHEDULED@

PRN @MEDSPRN@

Prior to Admission Meds @PTAMEDS@