Inpatient Sample Chart 2 Progress Notes

 Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts

PROGRESS NOTES

03/17

Subjective

afeb, no chillsor sweats

breathing better. on RA, sats ok

walking some

less wheezing and cough, still non productive

no nv/d/

no rash, itch

 

Health Status

Allergies: 

Allergic Reactions (Selected)

Moderate

Azithromycin- Hives.

Keflex- Hives.

Penicillins- Hives., 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

 

Problem list: 

All Problems

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

 

 

Objective

 

Vital Signs (last 24 hrs)_____      Last Charted___________

Temp Tympanic                                                36.6 DegC 

Heart Rate Peripheral                                     97 bpm 

Resp Rate                                                            18 br/min

SBP                                                                        H 149 mmHg

DBP                                                                        84 mmHg

 

General:  No acute distress  looks better

Mouth: no lesions, no thrush

Eye:  conjunctiva and sclera nl

Neck:  Supple. 

Respiratory:  Lungs clear bilaterally, no wheezes

Cardiovascular:  Regular rhythm, No murmur. 

Gastrointestinal:  Soft, Non-tender, Normal bowel sounds. 

Integumentary:  Warm, Dry, No rashes/lesions

Extremities: No peripheral edema noted

Neurologic:  Alert, No focal deficits noted

Psychiatric:  Cooperative.   

PICC;

Foley:

PIV:

 

Labs:

IgG level 1041

repeat blood cultures neg thus far

urine strep Ab pending

toxoplasma Ab pending

   

Impression and Plan

Community acquired pneumonia

   atypical organisms suspected given symptoms and CTA appearance

       RVP neg x 2

       BNP low

       PCT not elevated

bacteremia

      suspect contaminants: drawn at same site LAC. No indwelling or artificial devices

MS, not on immunosuppressants currently

hx pneumonia and sinusitis, consider CVID

     but IgG level is normal

 

 

REC:   D/W Dr XXX

           agree with change to po levoflox

           ok to discharge tomorrow if stable.

           plan 10 days total treatment with levoflox

 

03/16

Subjective

Asked to see for pneumonia

Pt reports rather sudden onset of SOA, cough, chest pressure 3 days ago. She has an underlying hx of asthma and uses and inhaler regularly along with prn nebulizer. She utilized those to the max allowed and sx nevertheless progressed. She went to her PCP office yesterday, 02 sats 85%. She was admitted. CXR with diffuse infiltrates, CTA chest with diffuse GGO, no thrombus. She has not been febrile, denies chills sweats. No HA, sore throat, swollen glands, GI upset, abd pain, diarrhea, blood in stool or urine, no dysuria, myalgias, rash, itch. Cough is dry, no hemoptysis, no chest pain.

RVP neg x 2

Has hx of pneumonia x 2, has received two pneumonia vaccine doses. Hx sinusitis, s/p surgery.

PMHx: MS, on a Q6month infusion, which was delayed by Covid, therefore no infusion for 9 months.

          chronic asthma

SHx: lives with husband, he has not been ill. One dog and 9 cats in the household. She smokes cigarettes, denies vaping.

FHx non contrib for infection problems

ROS: as above. 

 

Health Status

Allergies: 

Allergic Reactions (Selected)

Moderate

Azithromycin- Hives.

Keflex- Hives.

Penicillins- Hives., 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

 

Current medications:  (Selected)

Problem list: 

All Problems

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

   

Objective

Vital Signs (last 24 hrs)_____      Last Charted___________

Temp Tympanic                                                L 36.5 DegC 

Heart Rate Peripheral                                     95 bpm 

Resp Rate                                                            18 br/min

SBP                                                                        138 mmHg 

DBP                                                                        81 mmHg 

 

General:  No acute distress   alert, responsive

Mouth: no lesions, no thrush

Eye:  conjunctiva and sclera nl

Neck:  Supple. no nodes, thyroid normal 

Respiratory:  BS decreased bilat, with diffuse exp wheezes

Cardiovascular:  Regular rhythm, No murmur. 

Gastrointestinal:  Soft, Non-tender, Normal bowel sounds. 

Integumentary:  Warm, Dry, No rashes/lesions

Extremities: No peripheral edema noted

Neurologic:  Alert, No focal deficits noted

Psychiatric:  Cooperative.  

PICC;

Foley:

PIV:

 

Results Review

Impression and Plan

Community acquired pneumonia

   atypical organisms suspected given symptoms and CTA appearance

       RVP neg x 2

       BNP low

       PCT not elevated

bacteremia

      suspect contaminants: drawn at same site LAC. No indwelling or artificial devices

MS, not on immunosuppressants currently

hx pneumonia and sinusitis, consider CVID

 

REC: Agree with levoflox for empiric coverage.

         Check serum IgG

         urine strep pneumo antigen pending

          Will add additional serologies.

         repeat blood cultures

 

 

 

03/16

A/P

Acute Hypoxemic resp failure- background of asthma

   covid was negative x 2

   cont br tx, o2 support, wean as able

   on abx - levofloxacin, on iv steroids

 

 h/o MS

   last steroids were 1 mo ago

 

 Depression

   cont home meds

 

 Hypothyroidism

   cont levothyroxine

 

 Chronic pain

   resume home meds, avoid opioids if able

 

 other chronic conditions to be monitored and tx to be adjusted as needed

 

 PPX - dvt-heparin, gi-none needed

 

 Cont current care. Wean down o2 as able. She is still requiring a high amount of o2.

d/w family and pt at bedside - pt husband

 

Pt with no acute issues overnight. Feeling better.

 

  Temperature        36  

 Systolic Blood Pressure        124

 Diastolic Blood Pressure        67

 Pulse        88   

 SpO2        92  

 Respiratory Rate        20

 

  

General: conscious, coherent, nad

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender

Nose: nc in place

Respiratory: symmetrical chest expansion, bilat crackling noted

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: oriented x 3, no fd's noted, mmt 5/5

Psychiatric: not homicidal, not suicidal

 

Medications (24) Active

 Scheduled: (13)

albuterol-ipratropium Inh Sol 3 mL   NEB, BID

amitriptyline 25 mg Tab   8 tab(s), Oral, Once a day (at bedtime)

atorvastatin 20 mg Tab 1 tab(s), Oral, Once a day (at bedtime)

baclofen 10 mg Tab 2 tab(s), Oral, TID

busPIRone 10 mg Tab UD 1.5 tab(s), Oral, BID

diazepam 5 mg Tab 1 tab(s), Oral, TID

divalproex sodium 250 mg Tab ER(mg 3 tab(s), Oral, Once a day (at bedtime)

gabapentin 300 mg Cap mg 2 cap(s), Oral, QID

heparin 5000 units/mL Soln Subcutaneous, q8hr

levofloxacin  750 mg 150 mL, IV Piggyback, Q24hr

levothyroxine 100 mcg (0.1 mg) + levothyroxine 75 mcg (0.075 mg) Tab [mcg, Oral, Daily

methylPREDNISolone Sod Succ 40 mg Inj 2 vial(s), IV Push, q6hr

montelukast 10 mg Tab 1 tab(s), Oral, qPM

 Continuous: (1)

Sodium Chloride 0.9% 1,000 mL  1,000 mL, IV, 100 mL/hr

 PRN: (10)

acetaminophen 325 mg Tab mg 2 tab(s), Oral, q6hr

albuterol 2.5 mg/3 mL (0.083%) Sol UDmg 3 mL, NEB, q2hr

benzonatate 100 mg Cap mg 1 cap(s), Oral, BID

hydrOXYzine pamoate 25 mg Cap  cap(s), Oral, TID

magnesium oxide 400 mg Tab Oral, As Directed

magnesium sulfate 50% 2mL + Dextrose 5% in Water 100 mL 200 mL  2 gm 4 mL, IV Piggyback, As Directed

ondansetron 4 mg/2mL Inj Sol, IV Push, q6hr

oxycodone 5 mg Tab  1 tab(s), Oral, q6hr

potassium chloride 20 mEq ER Tab  1 tab(s), Oral, As Directed

Sodium Chloride 0.9% Inj Sol 10 mL flush , IV Push, UD

 

New Images

All images from this admission have been reviewed

 

no new images yet today

 

03/17

Subjective

Pt has migraine today, Up in room, ok to bathroom.

Review of Systems

Constitutional: [No fevers, chills, sweats]

 Respiratory: [+ shortness of breath, cough]

 Cardiovascular: [No Chest pain, palpitations, syncope]

 Gastrointestinal: [No nausea, vomiting, diarrhea]

 Genitourinary: [No hematuria]

 Peripheral- no claudication, no cramping

 

Objective

Vitals & Measurements

T: 36.7  °C (Tympanic)  TMIN: 36.0  °C (Tympanic)  TMAX: 37.0  °C (Tympanic)  HR: 103(Peripheral)  HR: 104(Peripheral)  RR: 20  RR: 20  BP: 147/82  SpO2: 96%  O2 Flow Rate: 4  O2 Therapy: Hi-flow nasal cannula  O2 Therapy: Hi-flow nasal cannula

 

Physical Exam

General: [Alert and oriented, well nourished, no acute distress].

 Neck: [Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy].

 Lungs: [Clear to auscultation and percussion, non-labored respiration].

 Heart: [Normal rate, regular rhythm, no murmur, gallop or edema].

 Abdomen: [Soft, non-tender, non-distended, normal bowel sounds, no masses].

 Musculoskeletal: [Normal range of motion and strength, no tenderness or swelling].

 Skin: [Skin is warm, dry and pink, no rashes or lesions].

 Neurologic: [Awake, alert and oriented X4, CN II-XII intact].

 Peripheral: No edema

 

Diagnostic Results

3/15 CT angio

1. No evidence of pulmonary emboli to the segmental pulmonary arteries.

2. Patchy and groundglass opacities throughout the lungs, suggestive of

COVID pneumonia.

3. Hepatic steatosis.

 

 3/15 CXR

Findings concerning for multifocal pneumonia. Recommend continued

follow up.

 

Assessment/Plan

42 y/o female

Acute Hypoxemic resp failure- background of asthma

   covid was negative x 2

   cont br tx, o2 support, wean as able- now on 2.5L

   on abx - levofloxacin, on iv steroids

   Consult ID- rec repeat serology, BC and other labs

   Afebrile

 

 h/o MS

   last steroids were 1 mo ago

 

 Depression

   cont home meds

 

 Hypothyroidism

   cont levothyroxine

 Chronic pain

   resume home meds, avoid opioids if able

 Migraine

   restart Fioricet prn

 PPX - dvt-heparin, gi-none needed

Cont current care. Wean down o2 as able. She is still requiring a high amount of o2.