Printable ICU Hospital Note

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Patient Name: Philip Mitchell
MRN: 123456789
Date: October 8, 2024
Time: 10:00 AM
Attending Physician: Dr. [Your Name]
Nurse: Kitty Johns, RN

Subjective:

The patient is a 65-year-old male admitted to the ICU with respiratory failure secondary to pneumonia. The patient reports feeling short of breath, especially when trying to speak. He is anxious but able to follow commands. The family is present and expresses concern about his condition.

Objective:

Vital Signs:

• BP: 110/70 mmHg

• HR: 98 bpm

• RR: 24 breaths/min

• SpO2: 88% on 6 L/min nasal cannula

• Temperature: 38.3 °C

Physical Exam:

• General: Alert, in moderate respiratory distress

• Respiratory: Decreased breath sounds bilaterally with crackles

• Cardiovascular: Regular rhythm, no murmurs

• Abdomen: Soft, non-tender, no distension

• Extremities: Warm, no edema

Labs:

• CBC: WBC 15,000/mm³

• BMP: BUN 25 mg/dL, Creatinine 1.5 mg/dL

• ABG: pH 7.35, pCO2 48 mmHg, pO2 55 mmHg

Assessment:

1. Respiratory failure secondary to pneumonia

2. Hypoxia requiring supplemental oxygen

3. Possible acute kidney injury (elevated creatinine)

Plan:

1. Continue supplemental oxygen and consider non-invasive ventilation (NIV) if no improvement.

2. Administer IV antibiotics (Piperacillin-Tazobactam 4.5 g IV every 8 hours).

3. Monitor vital signs and oxygen saturation closely.

4. Repeat ABG in 1 hour.

5. Consult nephrology for evaluation of renal function.

6. Discuss the patient's condition and plan with family.

Signature:

Dr. [Your Name], MD
Attending Physician

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