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 38.5Β°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 38.5Β°C, current temp 37.8Β°C, HR 88 bpm (range 60-100 bpm), BP 130/80 mmHg (range 120/80-140/90 mmHg), SpOβ 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 patientβs 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 SpOβ 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:
[Patientβs 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 β 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.)