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Open settingsInpatient Care & Hospital Admission Record
84 bpm
Sinus Rhythm118/76 mmHg
MAP: 90 mmHg99% SpO2
Nasal Cannula 2L98.8 °F
Normothermic15/15 GCS
Alert & Oriented+300 mL
In: 2400 / Out: 2100ICU Ward
Room ICU-1 · Bed B1
6 Days
Admitted 6 Days Ago
Nurse Alba
ICU Shift Leader
Under ICU Protocol
Chief Attending Review by Dr. Robert Chen, MD
Clinical Assessment & Progress:
58-year-old male admitted 6 days ago for acute cardiac decompensation. Patient remains hemodynamically stable on low-dose inotropic support. Telemetry shows sinus rhythm at 84 bpm without ventricular ectopy. Lungs show bilateral basilar crackles, improved from admission.
Diagnostic Imaging & Lab Summary:
• Bedside Echocardiogram: LVEF 42%, mild mitral regurgitation.
• Electrolytes: Serum Potassium 4.2 mEq/L, Sodium 138 mEq/L, Serum Creatinine 1.1 mg/dL.
• BNP: 420 pg/mL (trending down from 1,200 pg/mL on Day 01).
Plan of Care for Next 24 Hours:
1. Wean IV Furosemide drip to oral Torsemide 20mg twice daily.
2. Continue oxygen via nasal cannula at 2L/min to maintain SpO2 > 95%.
3. Evaluate for transfer from ICU Bed B1 to Step-Down Cardiac Telemetry Ward tomorrow morning if hemodynamics remain stable.
4. Low sodium (2g/day) cardiac diet protocol.
Scheduled IV & Oral inpatient administrations
| Drug & Route | Dosage | Frequency | Nurse Sign-off | Status |
|---|---|---|---|---|
| Furosemide (Lasix) IV | 40 mg (IV Push) | Q12H (08:00 & 20:00) | Nurse Alba, RN (08:05 AM) | GIVEN |
| Metoprolol Succinate | 25 mg (Oral Tab) | Once Daily (09:00 AM) | Nurse Alba, RN (09:02 AM) | GIVEN |
| Enoxaparin (Lovenox) SC | 40 mg (SubQ Syringe) | Once Daily (20:00 PM) | Scheduled 20:00 PM | DUE LATER |
Sequential record of hospital stay events
Emergency Admission
6 Days AgoAdmitted via ER with acute dyspnea and pulmonary congestion
ICU Bed Allocation (ICU-1 / Bed B1)
6 Days AgoTransferred to ICU under telemetry channel #04
Active Treatment & Inotrope Weaning
Day 06 ActiveConsultant rounds by Dr. Robert Chen • Preparing for step-down
Discharge Planning & Clearance
Target Day 08Post-discharge medication reconciliation and outpatient follow-up