Progress note examples

date and time
X is X years old, Nationality, Gender
a known case of
1.
2.
3.
4.
presented with (Admission details)
admitted as a case of (Admission Diagnosis)

Currently,
Vitals + fluid/stool chart

Examples of active issues below

Chest pain for investigation – ACS

• 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: antiplatelets, anticoagulation, beta blocker, ACEi, statins, etc.
• Consults: if seen by cardiology or respiratory, and any plans of CAG, PCI, etc.

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 complaints
• occupation & 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

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

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 the respiratory team, RT, OT, or PT

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 & environmental
• similar admissions/ICU admissions
• previous cultures and antibiotics used
• oxygen requirements (target 88-92%), BiPAP settings & 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 the respiratory team, RT, OT, or PT

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 the respiratory team, RT, OT, or PT

Ischemic stroke

• Symptoms and localization
• PMH: prior TIAs/CVA, HTN, DM, atrial fibrillation, peripheral vascular disease & CAD
• . Occupation & 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 & echocardiogram
• CT and if any follow up done with or without angiography or perfusion +/- MRI
• any intervention is done → thrombolysis etc
• Medications: antiplatelets, anticoagulants, antihypertensives, etc.
• Consult: if seen by neurology, cardiology, vascular surgery, and physiotherapy, including speech and swallowing assessment

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 anticholinergics, etc.
• Consult: if seen by neurology or ENT

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, antipsychotics, etc.
• Consult: if seen by neurology, geriatrics or psychiatry

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

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 & 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

Pancreatitis

• History: abdominal pain, nausea & 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/APACHE II/BISAP
• Medications: IVF rate, analgesics & antiemetics
• If caused by high TG: insulin therapy or plasmapheresis
• If caused by alcohol: is the patient in withdrawal, on vitamin supplements, on benzodiazepines
• Consult: if seen by gastroenterology, surgery or ICU

Decompensated cirrhosis

• History: Hepatic encephalopathy, GI bleed, or ascites
• PMH: liver disease, previous admission & 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 & fluid analysis
• Endoscopy if done
• Medications: Antibiotics, Laxatives, Diuretics, etc.
• MELD/Child-Pugh score
• Consult: if seen by gastroenterology or ICU

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

Nephrotic syndrome

• History: onset, edema status and progression, recent infections, hematuria & 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, antiplatelets or anti-coagulants, etc.

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

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

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

Infection/sepsis

• 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

Thromboembolic event (PE, DVT, etc.)

• History depends on the 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