Patient Name Age/Sex

Day of AcSU/ICU Stay Admission Date

Co-Morbidities
Overnight Events

HEAD TO TOE REVIEW

1. Neurology
GCS ____ (E___ V___ M____) Pain Scale:
Pain Meds

Neuro PE

2. CVS
BP: _______/_________ HR Pressors/ Nicardipine?
________ Dose____________
Rate_____________
Cardio PE
Inspection:
Auscultation:
Palpation:

3. Pulmonology
RR ________ O2 sat Neb/Face Mask/Cannula ______ LPM
___________
Mech Vent Mode____ TV______ PEEP_____ FiO2____ Breaths/min______ Inspi
Settings Flow______
Respi PE
4. GI
Bowel PEG Type of Type____________________
Movement Insertion Feeding Dilution__________________
Feeding Sched ____________
5. GU
I/O I_________ Freely Date of Fluids Type ____________________
O________ Voiding/ Insertion of Dose ____________________
Diff_______ Foley Foley Rate ____________________
Catheter ___________
Electrolytes Na______ K _______ Cl_______ Ca_______ Mg________
Other Electrolytes
6. IDS
Temp Antibiotics Antibiotic Day Dose/Rate
Given
CBC Results

C/S Results Type of Culture Organism S I R

7. Endocrine
CBG Monitoring Range________ Hypoglycemic Insulin: Other Hypoglycemic
Freq _________ Agent Type __________________ Agent/s
Unit ___________________
Frequency ______________
Endo Labs TSH__________ FBS ________ Chole__________ Other Labs
FT3__________ HbA1c______ TG____________
FT4__________ HDL___________
LDL ___________
VLDL__________
8. Others