Sample Inpatient Chart 3 Progress Notes

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PROGRESS NOTES

03/14

Neurosurgery Postoperative Check Note:

 

POD# 0 

ID: ZZZ is a 54 Y man with epidermoid tumor now s/p subtotal resection for decompression of nerves in the L cerebellopontine angle.

 

Subjective:

Doing well, minimal incisional pain

 

Objective:

Patient Vitals for the past 1 hrs:

                Temp    Temp Source      Pulse     BP           Resp      SpO2     O2 (LPM)             O2 Delivery

03/14/22 1315   —           —           78           120/75  13           99 %      —           —

03/14/22 1311   —           —           81           —           12           99 %      —           —

03/14/22 1302   —           —           80           —           15           99 %      —           —

03/14/22 1300   —           —           82           126/76  15           100 %    —           —

03/14/22 1254   97.1 °F (36.2 °C) Temporal Artery Scan     85           109/66  14           96 %      6 LPM   Simple Mask

 

Exam:

Aox4,

CN: PERRL, EOMI, nystagmus with L lateral gaze, VFF to finger count, face sensation symmetric, facial strength symmetric, hearing intact bilaterally, palate elevates, shoulder shrug intact, tongue midline

Motor: full strength BUE and BLE. No pronator drift

Sensation: intact to light touch in all extremities

Coordination: Mild left sided finger to nose dysmetria

Gait deferred

Incision: dressing c/d/i glue and stitches intact

 

 

Assessment: Recovering well postoperatively

 

Plan:

-Admit to 5S, PCNU protocol

-Decadron 4 mg Q6H, 1 week taper, pepcid

-MRI in AM w/wo contrast to evaluate tumor rsxn

-SBP < 150

-Wean to RA

-HOB at 30

-Advance diet as tolerated

-PT

-SCD

-Kefzol

 

03/15

Neurosurgery Daily Progress Note

 

Id: 54 YM

 

Brief Patient History: ZZZ is a 54 Y man with epidermoid tumor now POD1 s/p subtotal resection for decompression of nerves in the L cerebellopontine angle.

 

Date of Surgery: 3/14/2022

 

Interval History:

3/14: to OR, uncomplicated course, post op PACU and floor, mobilized, eating, voiding well

3/15: mild incisional pain responsive to Tylenol, MRI today, likely home today

 

Subjective:

Mild incisional pain otherwise doing very well

 Exam:

Aox4

CN: PERRL, EOMI nystagmus with left lateral gaze, visual fields full to confrontation, face muscles and sensation symmetric, hearing intact bilaterally, palate elevates symmetrically, shrug full, tongue midline

Motor: full strength BUE and BLE. No pronator drift

Sensation: intact to light touch in all extremities

Coordination: No finger to nose dysmetria

Gait cautious but well balanced

Incision: c/d/i glue intact

 

I/O 

Intake/Output Summary (Last 24 hours) at 3/15/2022 0711

Last data filed at 3/15/2022 0521

Gross over last 24 hours

Intake   3675 ml

Output 3150 ml

Net        525 ml

 

 Assessment/Plan:

Mr. ZZZ is a 54 Y man with epidermoid tumor now POD1 s/p subtotal resection for decompression of nerves in the L cerebellopontine angle. Recovering well.

 

-NOU

-Decadron taper.

-MRI w/wo contrast to evaluate tumor rsxn

-SBP < 150

-Wean to RA

-HOB at 30

-Regular diet

-PT

-SCD. SQH

-Likely to home today