Progress Note with Examples

Table Of Content

date and time
NAME is a AGE years old Nationality Gender
a known case of
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2.
3.
4.
presented with HPI
admitted as a case of ADMISSION DIAGNOSIS

Vitals: BP, HR, temp, oxygen saturation, RR, FBS and RBS
IVF, input and output chart, and type of diet, if on any vasopressors

Examples of common active issues:

CARDIOLOGY

I. Chest pain for investigation (unstable angina)

  • History: onset, duration, relation to exertion and breathing, previous episodes, associated symptoms: SOB, cough, diaphoresis, palpitations, neurological deficits, etc.
  • PMH: CAD, CAG, PCI +/- CABG
  • occupation and smoking
  • cardiopulmonary examination
  • CBC Hs-Troponin VBG BNP ECG and CXR
  • Grace score/Heart/TIMI scores
  • Medications: anti platelets, anticoagulation, beta blocker, ACEi, statins, etc.
  • Consults: if seen by cardiology or respiratory and any plans of CAG, PCI, etc.

II. Heart failure exacerbation

  • History: onset and progression, SOB on exertion and rest, PND, cough, LL edema, chest pain, palpitations, etc.
  • PMH: HF (any documented Echos), recent infection, compliance, previous admissions with similar complains
  • occupation and smoking
  • oxygen requirements
  • generalized and cardiopulmonary examination: JVP, ascites, LL, etc.
  • CBC BNP LFT RFT with electrolytes Hs-troponin TSH ECG and CXR
  • Medications: on any diuretics (home dose and current dose), SGLT2i, ACEi, etc.
  • Input and output chart
  • Consults: if seen by cardiology

III. Hypertensive emergency

  • History: chest pain, SOB, palpitations, headache, blurred vision, confusion, seizures, etc.
  • PMH: HTN, compliance, CKD on dialysis any missed sessions?
  • previous similar admissions
  • BP readings bilaterally
  • generalized, cardiopulmonary, and neurological examination
  • fundus examination
  • CBC Hs-Troponin BNP RFT with electrolytes and urinalysis
  • CXR +/- CT head
  • Medications: IV vs PO and which antihypertensives +/- diuretic

RESPIRATORY

I. Asthma exacerbation

  • History: SOB, cough, chest tightness, chest pain, palpitations, etc.
  • PMH: Asthma, compliance and technique, recent sick contact, allergies, etc.
  • similar admissions/ICU admissions
  • oxygen requirements
  • cardiopulmonary examination
  • CBC and ABG/VBG
  • CXR
  • Medications: nebulizers (SABA + SAMA) and frequencies, steroids, etc.
  • Consult: if seen by respiratory

II. COPD exacerbation

  • History: onset and progression, SOB, cough, chest pain, fever, sputum production, etc.
  • PMH: BiPAP or home oxygen, compliance and technique, recent sick contact, etc.
  • occupation, smoking and environmental
  • similar admissions/ICU admissions
  • previous cultures and antibiotics used
  • oxygen requirements (target 88-92%) BiPAP settings and timing
  • cardiopulmonary examination
  • CBC, ABG/VBG, HsTroponin, DDIMER and BNP
  • CXR previous PFTs/HRCT
  • Medications: nebulizers and frequencies, steroids, antibiotics etc.
  • Consult: if seen by respiratory, physiotherapist or respiratory technician

III. CAP/HAP

  • History: SOB, cough, sputum production and character, chest pain, etc.
  • PMH: underlying immunodeficiency or lung disease
  • recent admission, ventilation or aspiration
  • oxygen requirements
  • cardiopulmonary examination
  • CBC ABG/VBG LFT RFT CRP PCT +/- virology pannel and cultures
  • CXR +/- CT chest if complicated
  • If pleural effusion: tapping done, any fluid analysis?
  • complications: empyema, abscess, effusion, ARDS, or respiratory failure
  • CURB-65 score or PSI/PORT score
  • Medications: Antibiotics/Antiviral which day and dose (check if adjusted)
  • Consult: if seen by respiratory or any ID input

NEUROLOGY

I. Ischemic stroke

  • Symptoms and localization
  • PMH: prior TIAs/CVA, HTN, DM, atrial fibrillation, peripheral vascular disease and CAD
  • occupation and smoking
  • mechanism of stroke: large vessel atherosclerosis, embolic, small vessel disease, etc.
  • BP and neurological examination (NIHSS score)
  • CBC coagulation profile HbA1c lipid profile +/- thrombophilia and vasculitis workup
  • ECG +/- carotid imaging, holter monitor and echocardiogram
  • CT and if any follow up done with or without angiography or perfusion +/- MRI
  • if any intervention done -> thrombolysis etc
  • Medications: anti-platelets, anticoagulation, antihypertensive, etc.
  • Consult: if seen by neurology, cardiology, vascular surgery and physiotherapy including speech and swallowing assessment

II. Vertigo

  • History: onset, duration, relation to position, focal neurological deficit, nausea, vomiting, headache, tinnitus, hearing loss, recent infection, etc.
  • PMH: similar presentation
  • drugs history
  • Neurological examination
  • CBC RFT with electrolytes vitamin B12
  • ECG +/- audiogram
  • CT brain +/- MRI or follow up
  • Medications: vestibular suppressants: antihistamines, benzodiazepines and centrally-acting anticholinergic, etc.
  • Consult: if seen by neurology or ENT

III. Delirium

  • History: onset and pattern, current infection, medications list, constipation or urine retention, alcohol intake, nutrition status, etc.
  • PMH: neurocognitive impairment, vision or hearing loss
  • Neurological examination
  • CBC CRP RFT with electrolytes including RBS urinalysis cultures TSH cortisol, etc.
  • Neuro-imaging
  • Medications: benzodiazepines, antipsychotic, etc.
  • Consult: if seen by neurology or psychiatry

IV. Syncope

  • History: onset, duration, details pre and post event, neurological deficits, chest pain, palpitations, lightheadedness, dizziness, etc.
  • PMH: similar episodes, arrhythmias, epilepsy, etc.
  • Orthostatic vital signs, cardiology and neurology examination
  • CBC RFT with electrolytes including RBS Hstroponin
  • ECG
  • +/- holter monitor, EEG, neuro-imaging, Echocardiogram, etc.
  • Consult: if seen by neurology or cardiology

GASTRO

I. GI bleed

  • History: hematemesis, PR bleed, melena, symptoms of anemia, etc.
  • PMH: PUD, liver disease, diverticulosis, hemorrhoids, etc.
  • NSAIDs use
  • abdominal examination and stigmata of liver disease
  • stool chart
  • CBC (serial Hb) coagulation profile type and screen LFT and RFT
  • Endoscopy +/- Colonoscopy results (previous and current)
  • blood components reserved or transfused
  • Medications: PPI IV or oral or infusion, anti platelets or anticoagulation, prophylactic antibiotics or any vasoactive agents: terlipressin
  • Scores: UGIB Glasgow-blatchford score and LGIB Oakland score
  • +/- Forrest classification of bleeding peptic ulcers during endoscopy
  • Consult: if seen by gastroenterology, surgery or ICU

II. Pancreatitis

  • History: abdominal pain, nausea and vomiting
  • PMH: gallstone, alcohol intake, trauma, recent viral infection
  • drugs: steroids, azathioprine, loop and thiazide diuretics, etc.
  • previous episodes of pancreatitis
  • abdominal and pulmonary examination
  • CBC Amylase lipase LFT LDH CRP PCT ABG TG and serum calcium
  • ECG
  • U/S Abdomen +/- CT with contrast
  • severity: Ranson/APACHI II/BISAP
  • Medications: IVF rate, analgesics and antiemetics
  • If caused by high TG: insulin therapy or plasmapheresis
  • If caused by alcohol: is the patient in withdrawal, on vitamin supplementations, on benzodiazepines
  • Consult: if seen gastroenterology by surgery or ICU

III. Decompensated cirrhosis

  • History: Hepatic encephalopathy, GI bleed, ascites in previous liver cirrhosis patient
  • PMH: liver disease, previous admission and outpatient follow up
  • history of alcohol intake, NSAIDs, infection, dehydration, etc.
  • stool chart
  • CBC coagulation profile LFT RFT with electrolytes CRP PCT cultures and CXR
  • U/S abdomen +/- doppler if suspecting portal vein thrombosis
  • paracentesis if done and fluid analysis
  • Endoscopy if done
  • Medications: Antibiotics, Laxatives, Diuretics, etc.
  • MELD/Child-Pugh score
  • Consult: if seen by gastroenterology or ICU

NEPHROLOGY

I. AKI

  • etiology: dehydration, sepsis, recent NSAIDs/antibiotics/nephrotoxic drugs, obstructive symptoms, prostate hyperplasia, stones, etc.
  • symptoms of uremia: metallic taste, nausea, vomiting, etc.
  • generalized, fluid status, abdominal examination, etc.
  • Input/output chart: Is the patient on fluids/diuretics? Underwent dialysis?
  • RFT with electrolytes including the trend -> previous readings from OPD/previous admission/baseline creatinine
  • abdominal imaging: U/S Abdomen or CT KUB
  • Consult: if seen by nephrology or urology

II. Nephrotic syndrome

  • History: onset, edema status and progression, recent infections, hematuria and changes in BP
  • Mention edema: periorbital, pericardial, pleural, ascites, scrotal, sacral, and peripheral
  • PMH: recent infection, diabetes, lupus, RA, amyloid, etc.
  • fluids chart
  • generalized examination
  • CBC RFT coagulation profile albumin lipid profile +/- ESR CRP
  • urine analysis and 24 hour urine protein or PCR
  • U/S abdomen and pelvis +/- CTA/MRV if suspecting renal vein thrombosis
  • biopsy arranged and when?
  • nephrotic syndrome workup: AntiPLA2R antibodies, HbA1c, ANA, HBsAg, HCV Ab, C3 C4, underlying
    malignancy etc.
  • Medications: on diuretics, ACEi, anti-platelets or anti-coagulations, etc.

ENDOCRINE

I. DKA

  • History: abdominal pain, nausea, vomiting, dehydration, neurological symptoms, etc.
  • PMH: DM, medications and compliance, outpatient follow up, recent infection, trauma or surgery
  • abdominal examination
  • NPO vs. diet, DKA protocol with fluid rate, electrolytes replacement and if on basal insulin
  • CBC VBG RFT (anion gap, potassium and sodium), urine and serum ketones HbA1c Lipid profile
  • Infectious workup if suspected
  • Hs-troponin and ECG if suspected especially in older patients or with history of IHD
  • Consult: if seen by endocrine/diabetes team, diabetic educator or dietitian

II. Hypoglycemia

  • History: paresthesia, nausea, vomiting, palpitations, sweating, tremor, anxiety, altered mental status or seizures
  • PMH: DM, medications and compliance, Insulin use, alcohol use, malnutrition, underlying sepsis/infection, etc.
  • drugs history: beta-blockers, heparin, lithium, ACEi, ARB, etc.
  • similar episodes
  • consciousness level and generalized examination
  • glucose chart, corrections given and what type of maintenance fluid is the patient on
  • CBC LFT RFT
  • septic workup if needed
  • morning cortisol +/- synacthen if suspected adrenal insufficiency
  • hypoglycemia workup if sent including insulin, C-peptide, proinsulin, anti-insulin receptor
    autoantibodies, sulfonylurea and exogenous insulin levels
  • Consult: if seen by endocrine or ICU

HEMATOLOGY

I. Anemia

  • History: fatigue, SOB, palpitations, dizziness, etc.
  • bleeding including menses
  • ecchymosis, petechia, etc.
  • malabsorption, malnutrition hematological or chronic disease
  • PMH: hematological condition, on regular transfusions or iron injections/tablets
  • signs of anemia and generalized examination including PR
  • cross type and is there pRBCs reserved for the patient
  • CBC including MCV Iron studies vitamin B12 folate blood film retic count LDH LFT haptoglobin and coombs test -> mention baseline previous Hb and trend
  • U/S abdomen or endoscopy/colonoscopy if available
  • patient receive pRBCs, Iron or vitamin B12 replacement during admission
  • Consult: if seen by hematology, gastroenterology or surgery

OTHERS

I. INFECTION/SEPSIS (cellulitis, pneumonia, UTI, etc.)

  • History: fever, chills, rigors, cough, nausea, vomiting urinary symptoms, etc.
  • PMH: previous infections, immunodeficiency, recent admission within 90 days, recent antibiotics taken with duration etc.
  • examination related to infection: chest, abdomen, skin, etc.
  • WBC including differentials CRP PCT LFT RFT including eGFR or CrCl
  • all available cultures: blood, urine, sputum, CSF, stool, wound, etc. including TB or virology
  • CXR or CT chest in cases of pneumonia/empyema
  • U/S abdomen and pelvis or CT KUB in cases of complicated UTI or intra-abdominal infections
  • If cellulitis mention the progression
  • If drains mention the amount and character
  • on antimicrobial: which day and what are the doses?
  • any regular pain killers?
  • Consult: if any other team following up the patient

II. Thromboembolic event (PE, DVT, etc.)

  • History depending on location
  • PMH: of similar episodes, immobility, surgery, active malignancy, autoimmune diseases, nephrotic syndrome, vasculitis, thrombophilia, OCPs, HRT, etc.
  • CBC coagulation profile RFT ANA thrombophilia screen vasculitis screen antiphospholipid screen +/- cardiac biomarkers
  • ECG and CXR
  • U/S doppler limb or CTA, etc.
  • Medications: anticoagulation type and dose and if warfarin adjustment, thrombolysis or embolectomy in cases of severe PE
  • mention the other conditions the patient has and whether it is controlled, for example when you write at the beginning known case of DM you can mention:
  1. Time of diagnosis
  2. Follow up/primary physician
  3. Home medications
  4. Compliance
  5. Latest HbA1c
  6. Any complications


After the active issues
mention all medications the patient is currently on
mention that the patient is seen in the rounds with SENIOR DR.
Plan with Dr. X:
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2.
3.

MOC