ICU Discharge Note

Patient Name: Johan Green
MRN: 123456
Date of Admission: October 1, 2050
Date of Discharge: October 8, 2050
Attending Physician: Dr. [Your Name]
Consultants: Dr. Emily Brown (Pulmonology), Dr. Robert Green (Nephrology)
ICU Team: Dr. Alice Johnson, Nurse Mark Thompson

Reason for Admission:

The patient was admitted to the ICU for severe pneumonia requiring mechanical ventilation.

Clinical Summary:

  1. Initial Condition: The patient presented with respiratory failure due to pneumonia, necessitating intubation and mechanical ventilation on October 1, 2024.

  2. ICU Course: The patient was placed on a ventilator with settings: assist-control mode, FIO2 100%, and PEEP 10 cm H2O. Antibiotic therapy was initiated with piperacillin-tazobactam and vancomycin. The patient's respiratory status gradually improved, and sedation was minimized to facilitate weaning from the ventilator.

  3. Ventilator Weaning: Successful extubation occurred on October 5, 2024. The patient was transitioned to a nasal cannula at 2 L/min with stable oxygen saturation (SpO2 92-94%).

  4. Other Interventions:

    • Continuous monitoring of vital signs and laboratory values.

    • Diuretics were administered for fluid overload.

    • Renal function was stable, with adequate urine output throughout the ICU stay.

  5. Complications: No significant complications were noted during the ICU stay.

Discharge Condition:

The patient is clinically stable, alert, and oriented, with no signs of respiratory distress. The patient requires home oxygen therapy at 1 L/min via nasal cannula.

Follow-Up Recommendations:

  • Primary Care Physician: Follow-up appointment within 1 week post-discharge.

  • Pulmonology: Outpatient follow-up in 2 weeks for lung function assessment.

  • Medications:

    • Continue antibiotics: Amoxicillin-clavulanate 875/125 mg PO twice daily for 7 days.

    • Prednisone 20 mg PO daily for 5 days.

    • Furosemide 20 mg PO as needed for edema.

    • Oxygen therapy as prescribed.

Patient Education:

  • The patient and family were educated on the importance of medication adherence, signs of respiratory distress, and when to seek medical attention.

  • Instructions were provided regarding the use of oxygen therapy and maintaining follow-up appointments.

Discharge Instructions:

  • The patient may resume normal activities as tolerated.

  • Avoid smoking and exposure to respiratory irritants.

Signature:


Dr. [Your Name], MD
Attending Physician
Date: October 8, 2050

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