A subsequent hospital visit...

CC: Shock

INTERVAL HISTORY: Patient admitted last night with altered mental status. Found to have acute renal failure. Intubated later for hypoxemic respiratory failure. Remains on LEVOPHED and DOPAMINE.

CONSTITUTIONAL: Intubated, unresponsive, cachectic
VITAL SIGNS: BP 80/60, HR 122, 24
NECK: No JVD, trachea midline
LUNGS: CTA with symmetric breath sounds
CARDIOVASCULAR: RRR, no MRGs, no peripheral edema
ABDOMEN: Soft, decreased bowel sounds, no HSM
MUSCULOSKELTAL: Severe muscle wasting and atrophy

Labs: BUN 285, creatinine 7, HGB 5.8. Urine creatinine 345, urine sodium 22. ABG: pH 7.13, PaO2 128, PaCO2 40 on 40% FiO2.

IMPRESSION
1. Severe, improving ARF due to profound volume depletion
2. Worsening anemia
3. Worsening acidosis
4. Hypovolemic shock, not yet improving

PLAN
1. Another liter NS wide open
2. Then isotonic bicarb at 300 cc/hr
3. Transfuse 2 units PRBCs
4. Repeat chem. 7, CBC at 1400
5. Usual labs in a.m.

Total critical care time: 25 minutes