ICU Progress Note

ICU Progress Note — ICU Day 1 (post-transfer at 23:55 on 04/14/2026)

Patient: Donnelly, Margaret R.

DOB / Age / Sex: 09/12/1954 / 71 / F

MRN: CLH-3358104

Account #: CMCS-202604-073318

Member ID: XEH829104677

Insurance: Anthem Blue Cross PPO (Group SPP-PPO-2208)

Note Date/Time: 04/15/2026 08:15

Unit: Medical Intensive Care Unit (MICU) | Hospital Day: Hospital Day 2

Subjective

Patient reports feeling 'very weak' but less confused than on arrival. Endorses ongoing fatigue and mild right flank discomfort. Denies dyspnea, chest pain, headache. Husband at bedside, states she is 'back to recognizing everyone,' a clear improvement from last evening when she did not know the date and was difficult to engage. Mental status at this writing: AAOx3 (improved from AAOx2 / GCS 13 on ED arrival).

Note: portions of the HPI copied forward from the admission H&P for continuity — see admission note for full history.

Objective — Vital Sign Trend (past 24 hours)

Timestamp	Temp	HR	BP	MAP	RR	SpO2
04/14/2026 19:46 (ED)	103.0 F	122	84/48	60	24	93% RA
04/14/2026 21:30	102.4 F	116	90/54	66	22	96% 2L NC
04/14/2026 22:50 (repeat lactate)	101.8 F	110	86/50	62	22	96% 2L NC
04/14/2026 23:25 (norepi start)	101.5 F	108	82/49	60	20	97% 2L NC
04/15/2026 02:00	100.6 F	98	112/64	80	18	97% 2L NC
04/15/2026 08:00	99.4 F	92	118/70	86	16	98% RA

SOFA Assessment (Sepsis-3)

SOFA System	Points
Cardiovascular	+3
Renal	+2
CNS	+1
Respiratory	+0
Coagulation	+0
Hepatic	+0
Charted total	6

Acute SOFA increase from baseline 1 to a maximum of 6 — a rise of 5 points. Confirmed E. coli infection (urine and blood cultures positive).

Vasopressor Timeline

Drug	norepinephrine
Indication	MAP <65 despite completion of 30 mL/kg crystalloid (2040 mL LR completed prior to vasopressor).
Initiated	04/14/2026 23:25 at 2 mcg/min (AFTER completed 30 mL/kg crystalloid)
Peak Dose	10 mcg/min at 04/15/2026 ~01:00 (transiently)
Discontinued	Weaning; off at 04/15/2026 16:25 (approximately 17 hours total)
Access	Right internal jugular central venous catheter placed under ultrasound for vasopressor administration; post-procedure imaging confirmed appropriate tip position, no pneumothorax

Fluid Balance (past 24h)

Total In (24h)	3640 mL (2040 mL LR 30 mL/kg bolus + 1600 mL maintenance/medications)
Total Out (24h)	2150 mL (urine 1950 mL; insensibles ~200 mL)
Net Balance	+1490 mL

Physical Exam

General	Elderly woman resting in bed, no acute distress at this writing, oriented x3, cooperative.
Cardiovascular	Rate 92, regular. No murmur. Distal pulses 2+ symmetric. Capillary refill <2 seconds. Extremities warm, well perfused on weaning pressor.
Respiratory	RR 16, non-labored. Clear bilaterally. Weaned to room air this morning, SpO2 98%.
Abdomen	Soft. Mild residual right CVA tenderness. Non-distended, normal bowel sounds.
Neurologic	AAOx3, attentive, conversational, GCS 15.
Access	Right IJ triple-lumen central line (day 1), two peripheral IVs, Foley catheter draining clear yellow urine.

Current Medications

Norepinephrine gtt 2-10 mcg/min (weaning)
Ceftriaxone 2 g IV q24h (day 2)
Lactated Ringer's at 100 mL/hr
Pantoprazole 40 mg IV daily
Insulin sliding scale

Key Laboratory Data

wbc	18.5 K/uL with 14% bands (04/14 20:10)
lactateInitial	3.8 mmol/L (04/14 19:50)
lactateRepeat3h	2.4 mmol/L (04/14 22:50, after 30 mL/kg crystalloid)
lactateNextDay	1.6 mmol/L (04/15 06:00)
creatinineAdmit	2.4 mg/dL (baseline 1.3)
creatinineToday	2.6 mg/dL (04/15 06:00, still rising)
procalcitonin	8.2 ng/mL
crp	201 mg/L
bloodCultures	Escherichia coli, 2 of 2 sets positive at ~16 hours (pan-susceptible) — bacteremia
urineCulture	Escherichia coli >100,000 CFU/mL (pan-susceptible)
coags	INR 1.1, platelets 198 K/uL (no coagulopathy)

Assessment

One-liner for sign-out: 71F w/ T2DM/CKD3/HTN admitted with E. coli urosepsis and septic shock requiring norepinephrine, now stabilizing on ICU Day 1.

Septic shock secondary to E. coli pyelonephritis with E. coli bacteremia (2/2 blood culture sets positive). Acute SOFA increased from baseline 1 to a maximum of 6. Norepinephrine was required to maintain MAP >=65, and serum lactate was 2.4 mmol/L at three hours after completion of the full 30 mL/kg crystalloid resuscitation. The hypotension did not correct with the 30 mL/kg fluid bolus; norepinephrine was started only after that bolus was completed. AKI on CKD3 — creatinine rose from baseline 1.3 to 2.4 at admission and continues to rise (2.6 today). Lactate has down-trended (3.8 -> 2.4 -> 1.6) with source control and pressors. Mental status has returned to baseline. Not meeting criteria for mechanical ventilation.

Plan

Septic shock: wean norepinephrine as tolerated; goal off today. Maintain MAP >=65.
Source: E. coli pyelonephritis with bacteremia. Continue ceftriaxone; narrow per susceptibilities (pan-susceptible).
AKI on CKD3: creatinine still rising (2.6); continue to hold nephrotoxins, renally dose, monitor urine output and daily BMP. Anticipate peak in next 24-48h.
Volume status: net positive; transition to maintenance fluids once pressor off.
Glycemic control: insulin sliding scale; hold oral agents.
DVT prophylaxis: pneumatic compression while on pressors.
Disposition: anticipate de-escalation to general medicine within 24-48 hours if improvement continues.
Code status: Full code; reconfirmed with patient and husband.

____________________________

Stephen Halvorsen, MD — Critical Care Attending — Critical Care/Pulmonology — NPI 1740220031

Signed electronically: 04/15/2026 08:42

CONFIDENTIAL: This document contains protected health information. Unauthorized disclosure is prohibited by federal law (HIPAA).