Clinical Course:
Patient is a 68-year-old male with past medical history of hypertension, type 2 diabetes, and chronic kidney disease. Patient presented to City Hospital and admitted with the diagnosis of pneumonia with presenting chief complaint of shortness of breath and fever. Since admission, the patient has been started on IV antibiotics and oxygen therapy. His condition has shown gradual improvement with reduced fever and improved oxygen saturation levels.
Today's Updates 10/15/2023:
The patient's condition has stabilized with no significant events in the last 24 hours. He continues to respond well to the antibiotic regimen.
Relevant imaging results: Chest X-ray shows resolving infiltrates in the right lower lobe.
Relevant test results: Blood cultures remain negative, and inflammatory markers have decreased.
Review of Systems (ROS):
No new positive or negative findings reported.
Physical Exam:
General: Alert and oriented, well-nourished, no acute distress.
Lungs: Clear to auscultation, non-labored respiration.
Heart: Normal rate, regular rhythm, no murmur. No LE edema.
Abdomen: Soft, non-tender, non-distended, normal bowel sounds.
Musculoskeletal: No finger cyanosis.
Neurologic: No facial weakness.
Psychiatric: Cooperative.
Assessment and Plan:
68-year-old male with hypertension, type 2 diabetes, and chronic kidney disease, admitted for pneumonia.
1. Pneumonia
- Assessment: Improving with current treatment.
- Plan: Continue IV antibiotics and monitor respiratory status.
- Counseling: Discussed the importance of completing the antibiotic course and monitoring for any new symptoms.
2. Hypertension
- Assessment: Blood pressure well-controlled on current medications.
- Plan: Continue current antihypertensive regimen.
3. Type 2 Diabetes
- Assessment: Blood glucose levels stable.
- Plan: Continue current diabetic management and monitor blood glucose levels.
Fluids, Electrolytes, Diet: Patient on a regular diet with adequate hydration.
DVT prophylaxis: Enoxaparin sodium ordered.
Central line: Not applicable.
Foley catheter: Not applicable.
Code Status: Full Code.
Disposition: Expected discharge in 2 days with follow-up in the outpatient clinic for continued management of chronic conditions.
Clinical Course:
Patient is a [insert age] with past medical history of [insert past medical history]. Patient presented to [insert hospital name] (if patient was transferred from another hospital, state that the patient was admitted following a transfer and the transfer hospital's name. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) and admitted with the diagnosis of [insert admission diagnosis] with presenting chief complaint of [insert admission chief complaint]. Summarize the patient's clinical course since admission, including any significant events, changes in condition, or interventions. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Today's Updates [Insert date of current consultation in US format]:
[Describe the patient's condition and any significant events or interventions in the last 24 hours in a narrative format.] (Only include if explicitly mentioned in the transcript, otherwise state "No significant events in the last 24 hours.")
[Describe any new changes related to the significant events in a narrative format.] (Only include if explicitly mentioned in the transcript, otherwise leave blank.)
[Relevant imaging results and their interpretation that were obtained in the last 24 hours in a narrative format.] (Only include if available in the transcript or contextual notes, otherwise omit.)
[Relevant test results and their interpretation for the date of the note in a narrative format.] (Only include if available, otherwise omit.)
[Provide a summary of bedside questions responded to and education provided as mentioned in the transcript.] (Only include if explicitly mentioned in the transcript, otherwise leave blank.)
Review of Systems (ROS):
[List any relevant positive or negative findings from the review of systems.] (Only include if explicitly mentioned in the transcript, otherwise leave blank.)
Physical Exam:
[Describe the findings from the physical examination, including vital signs, general appearance, and specific system examinations.] (Only include if explicitly mentioned in the transcript, otherwise use the default below:)
General: Alert and oriented, well-nourished, no acute distress.
Lungs: Clear to auscultation, non-labored respiration.
Heart: Normal rate, regular rhythm, no murmur. No LE edema.
Abdomen: Soft, non-tender, non-distended, normal bowel sounds.
Musculoskeletal: No finger cyanosis.
Neurologic: No facial weakness.
Psychiatric: Cooperative.
Assessment and Plan:
[Patient's age, past medical history, and brief 1-3 sentence clinical course summary.]
1. [Medical issue 1 (condition name)]
- Assessment: [Current assessment of the condition.]
- Plan: [Proposed plan for management or follow-up.]
- Counseling: [Description of the condition, natural history, or similar.] (Include only if discussed, otherwise omit.)
2. [Medical issue 2 (condition name)]
- Assessment: [Current assessment of the condition.]
- Plan: [Proposed plan for management or follow-up.]
- Counseling: [Description of the condition, natural history, or similar.] (Include only if discussed, otherwise omit.)
3. [Medical issue 3, 4, 5, etc. (condition name)]
- Assessment: [Current assessment of the condition.]
- Plan: [Proposed plan for management or follow-up.]
- Counseling: [Description of the condition, natural history, or similar.] (Include only if discussed, otherwise omit.)
Fluids, Electrolytes, Diet: [Insert current IV fluids (if explicitly mentioned), electrolytes requiring replacement (if explicitly mentioned), and current diet (if explicitly mentioned). Otherwise, omit.]
DVT prophylaxis: [List the name of the ordered anticoagulant (e.g., Enoxaparin sodium, Heparin, Coumadin, Apixaban, Rivaroxaban) if explicitly mentioned, otherwise leave blank.]
Central line: [Insert "Present" (with indication for use) or "Not applicable" based on the transcript, otherwise leave blank.]
Foley catheter: [Insert "Present" (with indication for use) or "Not applicable" based on the transcript, otherwise leave blank.]
Code Status: [Insert Code Status (e.g., "Full Code," "DNR," "DNR/DNI," "DNI," "Comfort Care") if explicitly mentioned, otherwise leave blank.]
Disposition: [Insert the expected discharge date, pertinent medical issues affecting hospitalization, and discharge plans (rehabilitation, social services efforts) if explicitly mentioned, otherwise leave blank.]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note.)
