Inpatient progress note (Urology)

DAILY PROGRESS NOTE "Date of Service:" 11/01/2024 "Patient:" John Doe "DOB:" 05/15/1970 "MRN#:" 123456 Surgery: Radical Prostatectomy on 10/30/2024, POD 2 SYNOPSIS: This is a 54-year-old male with a history of prostate cancer, status post radical prostatectomy, currently recovering well. INTERVAL HISTORY: No significant overnight events. SUBJECTIVE: "I feel a bit sore but otherwise okay." OBJECTIVE: - Vital signs, last 24h: Temperature 98.6°F, Heart Rate 78 bpm, Blood Pressure 120/80 mmHg, SpO2 98%, RR 16 - Intake and Output: - Intake: 2000 mL - Output: 1800 mL - Drains: - Foley catheter in place, draining clear yellow urine PHYSICAL EXAM: - Abdomen: Soft, non-tender, surgical site clean and dry MEDICATIONS: "Scheduled Meds:" Acetaminophen 500 mg PO q6h "Continuous Infusions:" None "PRN Meds:" Oxycodone 5 mg PO q4h PRN pain LABS, IMAGING, AND OTHER STUDIES: "• Radiology: Recent imaging studies have been reviewed and are notable for no acute findings." "• Laboratory: All recent labs have been reviewed. Pertinent labs include normal CBC and electrolytes." "• Microbiology data: All recent micro results have been reviewed. Pertinent micro results include no growth." ASSESSMENT/PLAN: John Doe is a 54-year-old male patient of Dr. Smith, POD 2 from radical prostatectomy. 1. Prostate cancer, status post radical prostatectomy (ICD-10: C61) - Plan: Continue current pain management and monitor for complications. - Counseling: Discussed expected recovery timeline and signs of infection. 2. Postoperative pain (ICD-10: G89.18) - Plan: Continue acetaminophen and PRN oxycodone for pain control. 3. Foley catheter management - Plan: Monitor output and plan for removal on POD 3. 4. Fluids - Continue IV fluids at 75 mL/hr. 5. Electrolytes - Replete electrolytes PRN. 6. Diet - Advance to regular diet as tolerated. 7. Prophylaxis - Continue DVT prophylaxis with enoxaparin 40 mg subcutaneously daily. 8. Disposition - Inpatient, not appropriate for discharge planning at this time. ORDERS: - CBC and BMP tomorrow morning. "Signed by:" Dr. Thomas Kelly, MD “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”