CC: Multi-system organ failure

INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.

PHYSICAL EXAM: 96/60, 112, 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.

LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.

IMPRESSION

1. Hypoxic respiratory failure
2. Community acquired pneumonia
3. Septic shock
4. Non-oliguric acute renal failure

PLAN

1. Continue NS at 75 cc/hr
2. Decrease ZOSYN to 2.25 grams IV Q 6H
3. Follow cultures
4. Continue tube feeds
5. Titrate LEVOPHED to maintain SBP > 90
6. Usual labs ordered for tomorrow

Critical care time: 30 minutes and 1 second.

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