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