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ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.PHYSICAL EXAM: BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.IMPRESSION Hypoxic respiratory failureCommunity acquired pneumoniaSeptic shockNon-oliguric acute renal failurePLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6HFollow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90Usual labs ordered for tomorrow.Critical care time: 35 minutesWhat CPT® code(s) is/are reported?
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