EM Critical Care Note 2 plain - AAPC

Documentation Dissection

CASE 2 On Your Own

Critical Care SICU Progress Note

Visit Information

SICU Rounds Report

Admission Diagnoses Gallstone pancreatitis

Surgical Procedures Most recent washout and closure 2/1/10. S/P pancreatonecrotectomy, colectomy/cholecystecomy and evacuation of retroperitoneal hematoma, skeletonized celiac artery 12-30 Pert Trach #8 DCT

Take back to the OR 1/23 for bleeding OR with massive bleed/splenectomy 1/27 to OR on 2/6 for evac of left leg/groin abscess and femoral artery bypass and sartorius flap Femoral flap on 3/5 for definite wound closure. Hickman placement on 03/09 03-22--I/D of left groin site with wound vac placement 3/22--Plastics debridement and VAC to left groin wound 3/9--Green LIJ dual lumen hickman 3/5--Plastics. I&D Left groin. Muscle flap and z plasty. 2/22--Plastics. L groin wound flap and VAC. Vascular L groin debridement. 2/6--Vasc. L CFA to SFA bypass with saph vein graft. Sartorius flap. 2/1--Green. Re-opening recent laparotomy. Drainage of retroperitoneal sepsis. Abdominal closure with 20 x 25 cm

Strattice mesh.

1/29--G reen. Exploratory laparotomy with washout of intra-abdominal hemorrhage.Packing of left upper quadrant bleeding. Temporary abdominal closure.

1/27--Green. Control of massive hemorrhage with abdominal exploration, ligation of splenic vessel, splenectomy, pancreatic necrosectomy, and packing of hemorrhage with lap pads and replacement of VAC device. Vasc assist with hemorrhage control.

1/25,23,21,17,15,13,11,8,6,4; 12/31,30--Washout and temp abd closure. 12/30 Perc trach. 12/26--Reopening of laparotomy with removal of laparotomy pads, abdominal washout, open cholecystectomy with

intraoperative cholangiogram, construction of end ileostomy, temporary abdominal closure. 12/24--Reopening of laparotomy, abdominal washout, and packing of abdomen with laparotomy pads and temporary

abdominal closure with an Ioban and Vac-Pac. 12/24--Reopening of recent laparotomy, abdominal washout, packing of abdomen and placement of temporary

abdominal closure 12/23--Reopening of recent laparotomy with removal of temporary abdominal closure, pancreatic necrosectomy, total

abdominal colectomy, abdominal washout with placement of drains, temporary abdominal closure with Ioban Vac-Pac. 12/23--Opening of VAC pack and extending of abdominal incision, and evacuation of large clot.

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12/22--Exploratory laparotomy, major pancreatic necrosectomy, temporary abdominal closure with an Ioban Vac-Pac, drainage of intra-abdominal cavity with two sump drains.

Patient Info (last charted value)

Height(cm): 183.0 (03/22/10 10:26)

Admit Weight: 126.0 (03/28/10 21:00)

Dosing Weight: 126.0 (03/28/10 21:00)

BSA: 2.53 (03/22/10 10:26)

SCr: H 1.20 (03/29/10 04:18)

Allergy: Allergic Reactions (all) NKA

Events of last 24 hours Transferred to SICU for septic picture with fevers, tachycardia, and hypotension.

Physical Examination

Neurological/Psychiatric No anxiety or agitation. Glasgow Coma Score: Glasgow Coma Score. 3/29/2010 17:00 Glasgow Coma Score 9 3/29/2010 12:00 Glasgow Coma Score 10 3/29/2010 08:00 Glasgow Coma Score 11 No Restraints.

HEENT Normocephalic/Atraumatic (NCAT). Moist mucous membranes. Nasopharynx: Within normal limits. Oropharynx: Within normal limits. Pupils: normal. Neck: supple, trachea midline, #6 DCT trach in place. Eyes: PERRL- Pupil equal round and reacting to light, sclera white, conjunctiva clear.

Cardiovascular Regular rate and rhythm. No murmur, rubs or gallop. Tachycardia. Pulses: Radial (Right, 1+, Left, 2+).

Vital Signs (7 AM yesterday to 7 AM today)

Parameter

Last Charted

HR Monitored 122 (03/29 06:00)

SBP

90 (03/29 06:00)

DBP

53 (03/29 06:00)

Resp Rate

20 (03/29 06:00)

SPO2

100 (03/29 06:00)

FiO2%

40 (03/29 06:00)

MAP

65 (03/29 06:00)

Minimum 87 (03/28 22:00) 83 (03/28 18:10) 45 (03/28 18:10) 18 (03/29 01:00) 92 (03/28 09:18) 21 (03/28 08:00) 58 (03/28 18:10)

Maximum 122 (03/29 06:00) 101 (03/29 04:00) 68 (03/28 21:00) 27 (03/28 08:00) 100 (03/29 06:00) 40 (03/29 06:00) 79 (03/28 21:00)

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Cardiovascular Labs (last 4 charted values) Lactate: 1.5 03/29 04:1 1.3 03/28 16:2 Trop I: 0.05 03/10 06:4 0.02 02/15 21:5

1.5 03/28 10:1 0.02 02/15 14:3

Respiratory O2 Therapy: Ventilated (spontaneous, 40% 18/5). Clear to auscultation. Respiratory non-labored. Tracheostomy (#6 DCT). Decreased at bases.

Blood Gas (last 2 charted values)

Type:

Arter (03/29/10 04:10)

FiO2:

40 (03/29/10 04:10)

Temp:

37.4 (03/29/10 04:10)

pH:

L 7.312 (03/29/10 04:10)

PaCO2:

37.8 (03/29/10 04:10)

PaO2:

L 52.4 (03/29/10 04:10)

Base Excess: L -6.5 (03/29/10 04:10)

HCO3:

L 18.6 (03/29/10 04:10)

O2Hb:

L 87.4 (03/29/10 04:10)

Arter (03/28/10 16:20) 40 (03/28/10 16:20) 36.3 (03/28/10 16:20) C 7.251 (03/28/10 16:20) 36.6 (03/28/10 16:20) H 129 (03/28/10 16:20) L -10.4 (03/28/10 16:20) L 15.5 (03/28/10 16:20) 97.0 (03/28/10 16:20)

GI/Liver/Pancreas/Nutrition

Nutrition: Diet (NPO, Tube feedings, TPN).

Soft.

Distended.

Non tender.

No hepatosplenomegaly.

Decreased bowel sounds.

Wound dressing in place. JP x2 in place.

Glucose control:

3/29/2010 04:18

Glucose Level

3/28/2010 04:15

Glucose Level

136 mg/dL High 173 mg/dL High

Renal/Fluid/Electrolytes

Intake and Output: Link to I&O.

I & O: 7:00 AM Yesterday to 7:00 AM Today

Intake:

5774.00 ml (240.75 ml/hr)

Lactated Ringer

1000.00 ml (41.70 ml/hr)

Sodium Chloride 0.9% 350.00 ml (14.59 ml/hr)

Enteral Flushes

160.00 ml (6.67 ml/hr)

Enteral Tube Intake 960.00 ml (40.03 ml/hr)

Accordion 1, Flush

40.00 ml

(1.67 ml/hr)

Accordion 2, Flush

10.00 ml

(0.42 ml/hr)

Continuous Infusions 2704.00 ml (112.74 ml/hr)

Medications

550.00 ml (22.93 ml/hr)

Output:

2870.00 ml (119.67 ml/hr)

Jackson-Pratt 1

520.00 ml (21.68 ml/hr)

Jackson-Pratt 2

10.00 ml

(0.42 ml/hr)

Jackson-Pratt 3

30.00 ml

(1.25 ml/hr)

Wound Manager 2

90.00 ml

(3.75 ml/hr)

Wound Vac

335.00 ml (13.97 ml/hr)

Stool Volume

475.00 ml (19.81 ml/hr)

Urine Catheter

1410.00 ml (58.79 ml/hr)

Balance:

2904.00 ml

H 2.6 02/25 03:5 ................
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