A subsequent hospital visit for a patient with CVA and HTN...

CC: CVA and HTN

INTERVAL HISTORY: Patient remains intubated in the ICU following acute CVA with intracranial hemorrhage. No history can be obtained.

Review of systems cannot be obtained due to the fact that the patient is intubated and sedated.

CONSTITUTIONAL: Intubated, sedated, unresponsive.
VITAL SIGNS190/100, 72, 24
NECK: No JVD, trachea midline
LUNGS: CTA with symmetric breath sounds
CARDIOVASCULAR: RRR, no MRGs, no peripheral edema
ABDOMEN: Soft, NABS, no HSM

Labs: BUN 23, creatinine 1.2, HGB 11.8. ABG: PaO2 88/PaCO2 48 on 40% FiO2.

IMPRESSION

1. Severe HTN which is not yet controlled
2. CVA with ICH
3. Respiratory failure

PLAN

1. Start NICARDIPINE drip
2. Titrate to SBP 140 mm Hg
3. Increase vent rate to 22
4. Continue tube feeds
5. Chem 10, CBC in a.m.