Aiko Watanabe P-0000004527 | 82Y/F | ICU-3 | ICU DAY 4
Critical
O+ ·
Penicillin
· Code Status: Full Code
Attending: Dr. Wei Zhang · Nurse: Grace Owusu
Latest Vitals
| HR | 102 bpm |
|---|---|
| BP | 90/55 mmHg |
| MAP | 67 mmHg |
| SpO₂ | 91% |
| Temp | 38.4°C |
Active Problems
- Post-laparotomy, suspected sepsis
- Ventilator dependency (AC mode)
- Vasopressor requirement (Norepinephrine)
Fluid Balance (24h)
Intake: 1,050 mL · Output: 390 mL · Net: +660 mL
Family / Attendant Contact
| Attendant Name | Kenji Watanabe |
|---|---|
| Relationship | Son |
| Contact Phone | +880 1711-224567 |
| Note | Primary contact, available for consent; prefers evening calls |
| Time | HR | BP | MAP | RR | SpO₂ | Temp |
|---|---|---|---|---|---|---|
| 08:00 | 98 | 92/58 | 69 | 20 | 93% | 38.1°C |
| 09:00 | 100 | 90/56 | 68 | 19 | 92% | 38.3°C |
| 10:00 | 102 | 90/55 | 67 | 18 | 91% | 38.4°C |
Trend range:
Neurological
| GCS (E3V3M4) | 10 / 15 |
|---|---|
| Pupil Size | 3mm / 3mm |
| Pupil Reaction | Reactive / Reactive |
Pain & Sedation
| Pain Score (Numeric Rating Scale) | 2 / 10 |
|---|---|
| Sedation Score (RASS) | -2 |
| Sedative Medication | Midazolam infusion |
Current Settings
Mode
AC
FiO₂
60%
PEEP
8
RR
18
Tidal Volume
420 mL
EtCO₂
36 mmHg
Peak Pressure
28 cmH₂O
Plateau Pressure
22 cmH₂O
Minute Ventilation
7.6 L/min
I:E Ratio
1:2
Settings History
| Date/Time | Mode | FiO₂ | PEEP | RR | Tidal Volume | Doctor |
|---|---|---|---|---|---|---|
| 2026-08-12 10:00 | AC | 80% | 10 | 20 | 400 mL | Dr. Wei Zhang |
| 2026-08-13 14:00 | AC | 70% | 9 | 19 | 410 mL | Dr. Wei Zhang |
| 2026-08-15 08:00 | AC | 60% | 8 | 18 | 420 mL | Dr. Wei Zhang |
Total Intake (24h)
1,050 mL
Total Output (24h)
390 mL
Net Balance
+660 mL
Intake
| Time | Type | Item | Volume |
|---|---|---|---|
| 06:00 | IV | IV Fluids (NS) | 500 |
| 08:00 | Enteral | Enteral Feed | 300 |
| 12:00 | IV | IV Fluids + Antibiotic | 250 |
Output
| Time | Type | Item | Volume |
|---|---|---|---|
| 06:00 | Urine | Catheter | 180 |
| 10:00 | Urine | Catheter | 150 |
| 10:00 | Drain | Abdominal drain | 60 |
| Drug | Concentration | Rate | Route | Start | Status |
|---|---|---|---|---|---|
| Norepinephrine High Alert | 4mg/50mL | 8 mL/hr | Central Line | 2026-08-12 11:00 | Running |
| Midazolam High Alert | 50mg/50mL | 3 mL/hr | Central Line | 2026-08-12 09:30 | Running |
| Piperacillin-Tazobactam | 4.5g/100mL | 100 mL/hr | Peripheral Line | 2026-08-15 08:00 | Scheduled |
Lab Trend
| Test | Today | Yesterday | |
|---|---|---|---|
| Hemoglobin | 9.2 | 9.8 | View Trend |
| WBC | 18.4 | 16.7 | View Trend |
| Creatinine | 2.1 | 1.8 | View Trend |
| Lactate | 4.8 | 3.2 | View Trend |
ABG
pH
7.31
PaCO₂
48
PaO₂
78
HCO₃
20
SaO₂
91%
Lactate
4.8
Imaging
| Study | Date | Status | |
|---|---|---|---|
| Chest X-Ray (Portable) | 2026-08-15 07:30 | Reported | View Report Open PACS |
| Procedure | Date/Time | Performed By | Indication | Complications |
|---|---|---|---|---|
| Central Line Insertion | 2026-08-12 11:00 | Dr. Wei Zhang | Vasopressor access | None |
| Device | Site | Inserted | Status | Action |
|---|---|---|---|---|
| Central Venous Catheter | Right IJ | 2026-08-12 11:00 | Active | |
| Arterial Line | Left Radial | 2026-08-12 11:20 | Active | |
| Urinary Catheter | Indwelling Foley | 2026-08-12 09:30 | Active | |
| ET Tube | Oral, 7.5mm, depth 22cm | 2026-08-12 09:15 | Active |
Nutrition
| Type | Enteral |
|---|---|
| Rate | 50 mL/hr |
| Calories | 1200 kcal/day |
| Dietitian Note | High-protein formula, tolerating feeds |
Infection Control
| Status | Suspected |
|---|---|
| Site | Intra-abdominal |
| Culture | Blood culture pending |
| Antibiotic Therapy | Piperacillin-Tazobactam |
Doctor Round — Dr. Wei Zhang
2026-08-15 08:30
S: Overnight: SpO2 dipped to 88% at 03:00, FiO2 increased. Sedated, no agitation.
O: HR 102, BP 90/55, MAP 67, SpO2 91% on AC/FiO2 60%. Lactate 4.8 (up from 3.2).
A: Worsening sepsis with rising lactate, ventilator dependency continuing.
P: Escalate antibiotic coverage, repeat lactate in 4h, continue vasopressor titration.