SUBJECTIVE: The patient had no events overnight. He is awake and talkative with his family. His delirium seems to be slowly improving. Blood pressure remains a little bit elevated still. He is tolerating trach collar without any difficulties with a Passy-Muir valve in place. The patient states that he is coughing up some mild secretions, but they are not causing any issues. He remains afebrile. He is tolerating his enteral nutrition via a PEG tube.
OBJECTIVE:
VITAL SIGNS: Temperature 97.2, heart rate 86, respiratory rate 20, and pulse ox 99% on trach collar.
GENERAL: The patient is a (XX)-year-old Caucasian male who is alert, awake, and answering questions. Delirium is significantly improved.
HEENT: Oropharynx is moist. Pupils are equal, round, and reactive to light.
NECK: Tracheostomy is in place with Passy-Muir valve in place.
HEART: Regular rhythm, rate in the 80s without murmur.
LUNGS: Coarse breath sounds bilaterally but no adventitious sounds.
ABDOMEN: Soft, nontender to palpation. PEG tube in place.
EXTREMITIES: No edema. Good radial pulses.
NEUROLOGIC: Mentation is very reasonable. The patient is moving all four extremities spontaneously. He is holding a conversation but is still mildly confused as far as orientation.
SKIN: No rashes.
LABORATORY DATA: Reviewed. Portable chest x-ray: We have independently reviewed the film as well as radiology report. Mild bibasilar atelectasis but really no acute findings.
ASSESSMENT:
1. Acute hypoxemic respiratory failure, weaning from mechanical ventilation, currently on tracheostomy collar with Passy-Muir valve.
2. Acute pancreatitis.
3. Diabetes mellitus.
4. Accelerated hypertension.
5. Acute kidney injury, resolving.
6. Intensive care unit delirium/metabolic and toxic encephalopathy.
7. Morbid obesity.
8. Obstructive sleep apnea, on continuous positive airway pressure at home.
PLAN: Continue attempts with trach collar. The patient is tolerating Passy-Muir valve at this point. We will need to check with speech and nutrition about clearance to see when he can begin oral intake. Otherwise, we will continue enteral nutrition via his PEG for now. We will discuss with respiratory therapy about when we are going to begin capping his tracheostomy. The patient is not on any antibiotics at the moment. At some point, his PermCath will need to come out down the road. Hypertension seems to be an issue as well. Probably could use some diuretics starting as of tomorrow. The patient remains on heparin subcutaneous for DVT prophylaxis.
