Assessment & Plan Elements
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Subjectively, patient isn't complaining of symptoms associated with infection
Patient denies fever, chills, dizziness or diffuse pain.
Objectively, vital signs are within normal limits.
This is supported by the fact that the patient is afebrile, in normal sinus rhythm, with no episodes of tachycardia or bradycardia..
Quantitatively, relevant laboratory findings at this time are stable.
Patient's elevated lactate status on admission has since resolved.
Patient's most recent CBC showed no signs of leukocytosis with left shift; which is associated with infection.
Qualitatively, relevant physical exam findings at this time are not concerning for any acute disseminated infection.
This is supported by the fact that the patient's infection site is non-erythematous, mildly swollen, and clean.
This is consistent with the expected of the physiology associated with the normal healing process.
Patient has no rebound tenderness which would be suggestive of peritonitis.
Surgically, patient is post operative day 1 from debridement of bilateral thighs and suprapubic wounds with wound vac application.
Per surgical note, patient tolerated procedure well.
Patient's wound sites were debrided and cultured which grew MRSA and gram negative organisms.
Patient is also receiving negative pressure wound therapy, which will encourage the presence of granulation tissue, superficialization and reduction of lesion extension.
Medically, patient is currently tolerating treatment and medical management.
This is supported by the fact that the patient is currently receiving the following antibiotics without complaints or adverse effects:
- linezolid 600 mg in D5W 300 mL IVPB;
- vancomycin dosed 15mg/kg IV every 12 hours.
Therefore, our plan for today is to continue current antibiotic regimen which is linezolid (MRSA coverage, anti-toxin) & Zosyn.
In conclusion, my assessment is that the patient is presenting good tolerance to treatment with absence of complications.
Our goals for today are the following:
1. Ensure mean arterial pressure is greater than 65 mmHg
2. Administer tylenol as needed for pain and fever prevention.
3. Consult infectious disease for recommendations on further management.
Subjectively, patient isn't complaining of symptoms associated with infection
Patient denies fever, chills, dizziness or diffuse pain.
Objectively, vital signs are within normal limits.
This is supported by the fact that the patient is afebrile, in normal sinus rhythm, with no episodes of tachycardia or bradycardia..
Quantitatively, relevant laboratory findings at this time are stable.
Patient's elevated lactate status on admission has since resolved.
Patient's most recent CBC showed no signs of leukocytosis with left shift; which is associated with infection.
Qualitatively, relevant physical exam findings at this time are not concerning for any acute disseminated infection.
This is supported by the fact that the patient's infection site is non-erythematous, mildly swollen, and clean.
This is consistent with the expected of the physiology associated with the normal healing process.
Patient has no rebound tenderness which would be suggestive of peritonitis.
Surgically, patient is post operative day 1 from debridement of bilateral thighs and suprapubic wounds with wound vac application.
Per surgical note, patient tolerated procedure well.
Patient's wound sites were debrided and cultured which grew MRSA and gram negative organisms.
Patient is also receiving negative pressure wound therapy, which will encourage the presence of granulation tissue, superficialization and reduction of lesion extension.
Medically, patient is currently tolerating treatment and medical management.
This is supported by the fact that the patient is currently receiving the following antibiotics without complaints or adverse effects:
- linezolid 600 mg in D5W 300 mL IVPB;
- vancomycin dosed 15mg/kg IV every 12 hours.
Therefore, our plan for today is to continue current antibiotic regimen which is linezolid (MRSA coverage, anti-toxin) & Zosyn.
In conclusion, my assessment is that the patient is presenting good tolerance to treatment with absence of complications.
Our goals for today are the following:
1. Ensure mean arterial pressure is greater than 65 mmHg
2. Administer tylenol as needed for pain and fever prevention.
3. Consult infectious disease for recommendations on further management.
Result - Copy and paste this output: