Urologist-Vorlage
Inpatient Rounds - follow up
Eine professionelle Urologist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a quick and efficient way to document inpatient urology rounds? This Inpatient Rounds - Follow Up template is designed for urologists to streamline their note-taking. It helps you capture essential information like patient history, vital signs, physical exam findings, lab results, and a detailed assessment and plan. This template ensures comprehensive documentation, saving you time and improving accuracy. With Heidi, this template can be quickly populated from your patient visit transcript, making your documentation process faster and more efficient. This template is perfect for urologists looking to improve their clinical documentation.
Vorlagenvorschau
DAILY PROGRESS NOTE
SYNOPSIS:
A 68-year-old male with a history of prostate cancer, status post-radical prostatectomy, and recent urinary retention. He is admitted for management of a urinary tract infection and ongoing urinary retention.
24 HOUR EVENTS:
Patient had a fever of 38.5°C. Blood cultures were drawn. Foley catheter was irrigated and yielded purulent material. Patient reported increased suprapubic discomfort.
SUBJECTIVE:
Patient reports, "I'm still having a lot of trouble passing urine, and the pain is getting worse."
OBJECTIVE:
"Vital signs last 24h:" Max temp 38.5°C, current temp 37.8°C, HR 88 bpm (range 60-100 bpm), BP 130/80 mmHg (range 120/80-140/90 mmHg), SpO₂ 98% (range 95-100%), RR 18.
"Intake and Output:" Intake 1500 mL, Output 1200 mL in last 24 hours; Intake 500 mL, Output 400 mL in last 8 hours.
"Drains:" Foley catheter.
PHYSICAL EXAM:
Abdomen soft, non-tender to palpation. Suprapubic tenderness present. Foley catheter patent with cloudy urine.
LABS, IMAGING, AND OTHER STUDIES:
"Radiology: Recent imaging studies have been reviewed and are notable for" No recent imaging.
"Laboratory: All recent labs have been reviewed. Pertinent labs include" Creatinine 1.1 mg/dL (stable), Hematocrit 38% (stable).
"Microbiology data: All recent micro results have been reviewed. Pertinent micro results include" Blood cultures pending. Urine culture pending.
ASSESSMENT AND PLAN:
68-year-old male with prostate cancer, urinary retention, and UTI.
1. Urinary Tract Infection
Assessment: Patient is showing signs of systemic infection, with fever and increased suprapubic pain. Blood and urine cultures are pending.
Plan:
* Continue IV antibiotics (Ceftriaxone) as prescribed.
* Monitor vital signs, including temperature, every 4 hours.
* Monitor urine output and characteristics.
* Repeat urinalysis and urine culture in 24 hours.
* Administer IV fluids as needed.
* Consult infectious disease if blood cultures are positive.
2. Urinary Retention
Assessment: Patient continues to experience urinary retention, despite Foley catheter placement.
Plan:
* Continue Foley catheter irrigation with sterile saline.
* Assess for catheter blockage or kinking.
* Consider bladder scan to assess for residual urine after catheter removal.
* Educate patient on signs and symptoms of urinary retention.
3. Prostate Cancer
Assessment: Patient is status post-radical prostatectomy and is being monitored for recurrence.
Plan:
* Review PSA results when available.
* Schedule follow-up appointment with oncologist as needed.
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