House Officer’s ROGRESS NOTES: Summary

House Officer’s ROGRESS NOTES:      by Dr M Tauseef Omer

Subjective: Patient resting comfortably? Sick? Very Sick ? Active ? Good cry ?
Pink with Oxygen inhalation @ (say) 2 L/min or Pink in room air ?   Playful ? Complaints or issues over night? Fevers? Pain? Tolerating PerOral ? Include all relevant details from the night before.

Objective:  Vital signs(Pulse rate, R.R , B.P , CRT, spO2,temp )
 Weight (Weight change), I/O, UOP, Physical exam positive findings  .
  Latest Meds and labs can be listed in the margin or in this section.
IS THE PATIENT’S abnormal EXAMINATION finding of PAST improved yet ? Or is there any Newer finding ?

Issues:

For example:
 Tachypnea
 Oxygen dependence
 fits not controlled on inj phenytoin 5mg/kg/day
 low urine output
 consolidation of right upper lobe
 high TLC

 Low platelet count
 raised pCO2 in ABGs
 

 PLAN:

Plan should address all the issues of the patient.
It should start from your very basic plan of management to advanced therapy you may consider. Like:
i) continue oxygen inhalation via NG in nostril @ 1 L/min
ii) intermittent spO2 monitoring
iii) Keep cleared airway

iv) keep NPO as R.R is very high .
v) continue same A/B

vi) rehydrate the patient and monitor urine output
vii) monitor BSL

viii) increase dose of phenytoin from 5 to 7mg/kg/day
ix) if pCO2 goes beyond 60mmHg, consider Mechanical Ventilation

x) Monitor for bradypnea, ASOC, FITS, anuria, cardiac failure
xi) counsel father regarding patient’s current condition
xii) Consult Senior onCall regarding further management plan for rising pCO2

and so on.

(Plan illustrates how much you have been thinking for your patient).

§  Things to keep in mind in every patient :

·         Can I start patient per Oral/  advance the diet/ keep NPO / ?

·         What supplies/home health does the patient need for home if being discharged?

·      Why does the patient still need to be in the ICU/hospital?     

“There is no more difficult art to acquire than the art of observation, & recording it in plain & brief language ”

Dr . William Osler
Father Of Medicine