Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Briefly describe the presenting symptoms and current clinical picture.
Examples: bleeding manifestations (petechiae, ecchymosis, mucous membrane bleeding), signs/symptoms related to underlying condition triggering DIC.
Note any recent changes in bleeding or clinical status.
Objective:
Vital Signs: Include heart rate, blood pressure, respiratory rate, oxygen saturation (SpO2)
Physical Exam:
General: Assess for signs of bleeding (e.g., petechiae, ecchymosis, mucous membrane bleeding) and organ dysfunction.
Specific findings may depend on the underlying cause of DIC.
Labs:
Coagulation studies:
PT (prothrombin time)
PTT (partial thromboplastin time)
INR (international normalized ratio)
Fibrinogen level
D-dimer level
Complete blood count (CBC) with differential: Look for abnormalities like thrombocytopenia.
Other labs as indicated by the underlying condition (e.g., electrolytes, kidney function tests, liver function tests)
Imaging:
Mention any relevant imaging studies performed (e.g., CT scan, ultrasound) to evaluate for bleeding source or underlying cause.
Assessment:
Presumed diagnosis of DIC based on clinical criteria and laboratory findings (mention specific scoring system used if applicable).
Identify the underlying cause of DIC (e.g., sepsis, trauma, malignancy).
Severity of bleeding and organ dysfunction.
Plan:
Management of the underlying condition:
Summarize the plan for addressing the cause of DIC (e.g., antibiotics for sepsis, surgical intervention for bleeding source).
Hemostatic Therapy: Consider the specific needs of the patient and potential risks of bleeding vs. thrombosis.
Options may include:
Blood product replacement (e.g., platelets, plasma, cryoprecipitate)
Anticoagulation for specific situations (use with caution)
Supportive Care:
Maintain hemodynamic stability with fluids and vasopressors if needed.
Manage specific bleeding complications.
Monitor for signs of organ dysfunction.
Consultation:
Consider consultation with hematology or critical care depending on the complexity of the case.
Follow-up:
Schedule frequent monitoring of coagulation studies and clinical status.
Indicate next steps for reevaluation and treatment adjustments.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant findings and interventions related to DIC management.