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.
DAILY PROGRESS NOTE
SYNOPSIS:
[Patient age and gender in conversational format, followed by a summary of the patient’s urologic situation in no more than three sentences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
24 HOUR EVENTS:
[Significant events, labs, or imaging in last 24 hours. Do not include information older than 24 hours. If no significant overnight events, omit this section.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SUBJECTIVE:
[Subjective information from the patient's point of view. Use direct quotes only if explicitly mentioned and appropriate.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
OBJECTIVE:
"Vital signs last 24h:" [Vital signs data in last 24 hours: max temp over 24 hours, current temperature and range, current heart rate and range, current blood pressure and range, current SpO₂ and range, respiratory rate if available. Omit this section if no vital signs available.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write on one line.)
"Intake and Output:" [Intake and output over last 24 hours and last 8 hours. Omit if no I/O mentioned.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write on one line.)
"Drains:" [Current drains including urologic and relevant non-urologic drains (e.g., Foley catheter, JP drain, internal ureteral stent, externalized ureteral stent, nephrostomy tube, nephroureteral stent, NG tube). Write on one line.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PHYSICAL EXAM:
[Physical exam details. Include only if mentioned. Omit if no physical exam performed or documented.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LABS, IMAGING, AND OTHER STUDIES:
"Radiology: Recent imaging studies have been reviewed and are notable for" [Radiology findings from the last 24 hours. Omit if none available.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"Laboratory: All recent labs have been reviewed. Pertinent labs include" [Creatinine with trend of last 2 values and hematocrit with trend of last 2 values if available. Omit if not within last 24 hours.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"Microbiology data: All recent micro results have been reviewed. Pertinent micro results include" [Pertinent microbiology results from the last 24 hours. Omit if none available.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASSESSMENT AND PLAN:
[Patient’s age and a brief list of their urologic medical issues only. Exclude any non-urologic issues.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
1. [Medical issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment: [Current assessment of the condition.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Detailed bulleted plan including current treatment, rationale, monitoring, and any alternative treatments discussed. Each bullet should be a separate management point.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [Medical issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment: [Current assessment of the condition.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Detailed bulleted plan including current treatment, rationale, monitoring, and any alternative treatments discussed.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. [Medical issue 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment: [Current assessment of the condition.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Detailed bulleted plan including current treatment, rationale, monitoring, and any alternative treatments discussed.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(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. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output; just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
