Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): This may not be applicable as ARDS patients are often critically ill and require mechanical ventilation.
History of Present Illness:
Summarize the reason for hospitalization and the clinical setting leading to ARDS development (e.g., pneumonia, sepsis, aspiration, trauma).
Onset and duration of respiratory symptoms (shortness of breath, tachypnea, hypoxia).
Past medical history (underlying lung disease, risk factors for ARDS).
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – Focus on respiratory rate, oxygen saturation on FiO2 (fraction of inspired oxygen).
Chest examination:
Use of accessory muscles for breathing
Auscultation findings (rales, wheezing) – may vary depending on the cause of ARDS.
Laboratory Findings:
Arterial blood gas (ABG): Hypoxia (low PaO2), respiratory acidosis (low pH, high PaCO2).
Chest X-ray: Bilateral infiltrates (fluid in the lungs) – characteristic finding of ARDS, but not specific for cause.
Other Studies (as indicated):
Sputum culture: To identify the causative organism (if pneumonia is suspected).
Blood cultures: To identify sepsis as a potential cause.
Assessment:
Diagnose ARDS based on the Berlin definition criteria (oxygen requirement, chest x-ray findings, respiratory mechanics).
Specify the severity of ARDS (mild, moderate, severe) based on PaO2/FiO2 ratio.
Identify the underlying cause(s) of ARDS.
Assess for potential complications of ARDS (ventilator-associated pneumonia, barotrauma, pneumothorax).
Plan:
Mechanical ventilation:
Set ventilator settings (tidal volume, PEEP) to optimize oxygenation and minimize ventilator-induced lung injury (VILI).
Monitor ventilator parameters and adjust as needed.
Oxygen therapy: Provide supplemental oxygen to maintain target oxygen saturation levels.
Treating the underlying cause: Address pneumonia with antibiotics, manage sepsis with appropriate source control and hemodynamic support.
Fluid management: Maintain hemodynamic stability while avoiding fluid overload that can worsen ARDS.
Sedation and analgesia: Provide comfort and minimize patient-ventilator dyssynchrony.
Prophylaxis for ventilator-associated pneumonia (VAP).
Consults:
Pulmonary critical care medicine
Other specialists depending on the underlying cause (e.g., infectious disease, trauma surgery)
Progress Notes:
Document daily assessments including vital signs, respiratory rate, oxygenation (ABG, SpO2), ventilator settings, chest exam findings.
Note changes in lung mechanics, presence of ventilator-associated complications (e.g., barotrauma, pneumothorax).
Monitor for signs of improvement (decreasing oxygen requirement, resolving infiltrates on chest x-ray).
Update the plan as needed based on the patient’s response to treatment and development of complications.
Prognosis:
ARDS carries a high mortality rate, especially in severe cases.
Prognosis depends on the severity of ARDS, underlying cause, and presence of co-morbidities.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Management of ARDS requires close monitoring and expertise in critical care medicine.