Prepared by: Nurse [Your Name]
Date: October 5, 2053
The patient, Jake Willms, a 65-year-old male, has shown signs of deterioration over the last few hours.
Current vital signs: Blood Pressure 90/60 mmHg (down from 120/80 mmHg), Heart Rate 110 bpm (up from 85 bpm), Respiratory Rate 28 breaths per minute (up from 18 breaths per minute), Temperature 101.2°F.
Admitted three days ago with community-acquired pneumonia.
History of hypertension and type 2 diabetes.
Receiving IV antibiotics and supportive care.
Initial improvement was noted; however, deterioration has occurred in the last 6 hours.
Vital signs suggest hemodynamic instability and potential infection progression.
Symptoms: increased shortness of breath, decreased urine output (< 30 mL/hr), altered mental status (confusion, disorientation).
Physical findings: bilateral crackles on lung auscultation, increased work of breathing.
Immediate review and possible intervention by the attending physician.
Consider ordering: repeat chest X-rays, arterial blood gases (ABGs), and blood cultures.
Recommend escalation to the Intensive Care Unit (ICU) for closer monitoring and advanced support.
Evaluate the need for vasopressors if there is no response to fluid resuscitation.
Templates
Templates