UCSF Progress Notes
Worktype 05
Turn-around time: 4 hours
These are STAT reports and should NOT be sent to editing. Please contact a
supervisor if assistance is needed. If no supervisor is available please send the report
through and send a note to the supervisor with your concern.
These are inpatient reports, so no letterhead is needed and no signature block is
needed.
These are very straightforward, most just a paragraph or two, some longer.
You do not need to put in the titles PROGRESS NOTE and DATE OF SERVICE at the
top of the report, this is done in postprocessing. If another title is dictated such as
SURGEON'S PREOPERATIVE NOTE or POSTOPERATIVE NOTE, you can type this at
the beginning of the report.
Type progress notes as dictated; no need to add artificial headings.
***As always, no patient names in reports***
See following pages for examples of progress notes, as well as specific physician
examples:
EXAMPLES:
UCSF Progress Notes
Work type 5
Turn-around time: 3 hours
EXAMPLES:
Andrew Posselt, MD #23141:
The patient is postop day 1 after a laparoscopic Roux-Y gastric bypass. She is doing quite well.
She does continue to have some headaches, but she does not have any significant abdominal
pain. On physical examination, she vital signs are stable. Her blood pressure is 160/90. Her O2
saturation is 98% on 2 L nasal cannula. Her chest is clear bilaterally. Abdomen is soft, slightly
distended and her incisions are all healing well, and she has only trace fluid in her Jackson-Pratt
drain.
Overall, the patient is doing very well. She will have hemodialysis performed today for her
chronic renal failure, and we will hopefully also obtain an upper GI study today. If this is not
possible, we will slowly initiate oral intake and monitor her closely.
With respect to her hypertension and headache, we will initiate her antihypertensive medications
today once she is able to take oral intake, and in addition we will give her Vicodin for her
headache, which has worked well in the past.
Posselt Sample 2:
The patient is postoperative day 5 after exploratory laparotomy and ventral hernia repair. He
developed atrial fibrillation in the recent past but has remained stable with his current Diltiazem
regimen. He does seem to be going back and forth between sinus rhythm and atrial fibrillation.
He is being transferred later today to the Stepdown Unit since he has shown significant
improvement over the last 24 hours.
On physical exam he is afebrile. Vital signs are stable. He continues to require oxygen on the
order of 6 liters by nasal cannula with oxygen saturations of 94-95%. His chest shows decreased
breath sounds and some rhonchi on the right side but otherwise is clear. His abdomen is soft.
His incision is healing well and he has no lower extremity edema.
His laboratory studies are unchanged.
Overall the patient is showing some improvement. We will monitor him on the Stepdown Unit
today, encourage ambulation and rate control will continue with Diltiazem. His epidural has been
removed and we will initiate oral pain medications.
Scot H. Merrick, MD # 26433
SURGEON'S PREOPERATIVE NOTE: This patient was admitted to UCSF with acute bacterial
endocarditis and severe heart failure. He recently developed pulmonary edema requiring
intubation. He is now scheduled for urgent aortic valve replacement. This has been
recommended by myself and Dr. Kanu Chatterjee. I discussed the procedure in detail with his
wife and daughter.
They understand the possible risks, complications (including death, myocardial infarction,
bleeding, infection, stroke), alternatives and outcomes.
Merrick Sample 2:
POSTOPERATIVE NOTE: The patient is postop after aortic valve replacement. She is doing
well on the ward. She has no specific complaints today. She is afebrile and her cardiovascular
system is stable. Her rhythm remains atrial flutter. The ventricular response is controlled. Her
examination is unchanged. An echocardiogram was performed yesterday showing left ventricular
function and normal prosthetic valve function. She is continuing on low dose Coumadin and
amiodarone with anticipated discharge tomorrow.
Merrick Sample 3:
POSTOPERATIVE NOTE: The patient is postoperative day 5 after a redo coronary bypass
surgery. He is in the Intensive Care Unit, extubated and doing quite well. His blood pressure is
now in the 130 range. His rhythm remains sinus. He has no major complaints. On exam, his
lungs reveal some scattered wheezes. His sternal wound is healing nicely.
Labs today show a hematocrit of 31 and a stable BUN and creatinine. His chest x-ray looked
quite good today. Our plan will be to discontinue the dobutamine, central line, and send the
patient to the ward.
John P. Roberts, MD # 41192:
This patient is status post kidney transplantation. His postoperative course has been complicated
by rejection. He is currently undergoing treatment with Thymoglobulin. Today he states that he
is feeling fairly well.
He is afebrile, blood pressure 165/100, pulse 74, respirations 18, and oxygen saturation 98% on
room air. His urine output is approximately 3 L. His wound is clean and dry, without evidence of
inflammation. His chest is clear. His heart has a regular rate and rhythm. He has no peripheral
edema.
His laboratories demonstrate a fall in his creatinine from 5.9 to 4.9. His potassium is slightly
elevated at 5.7. Hematocrit is 30.6.
With respect to immunosuppression, he is receiving CellCept, Solu-Medrol, and Prograf. He is
also receiving the Thymoglobulin therapy.
Roberts Sample 2:
This patient is status post solitary pancreas transplant, recently discharged from the hospital. He
came back with abdominal pain and severe diarrhea. The diarrhea started yesterday associated
with eating a sandwich, but his wife did not get ill. His abdominal pain is crampy in nature,
infraumbilical; no clear exacerbating or alleviating factors, but it did come on with the onset of
diarrhea. On physical examination, he is afebrile, his blood pressure is 142/89, pulse 83,
respirations 14, 95% on room air. He looks relatively well, though he is in some pain. His sclerae
are nonicteric. His neck is supple. Trachea is midline. His chest is clear to auscultation. His
heart has a regular rate and rhythm without murmurs, rubs or gallops. His abdomen is not
distended; it is soft. It has some tenderness in the lower quadrant, but he has active bowel
sounds without sounds consistent with obstruction.
His KUB shows what is either an ileus or an early small bowel obstruction. His white count is not
particularly elevated and his renal function is good. My sense is that he probably has some sort
of gastroenteritis, probably Clostridium difficile colitis and needs diagnosis of this. I think it is
unlikely that he has a small bowel obstruction given his clinical symptoms and the diarrhea.
We will test his stools for the various culprits and plan further therapy based on these cultures.
Amandeep Shergill, MD # 41807 (dictates for Terrault):
CHIEF COMPLAINT: Human immunodeficiency virus and nodular regenerative hyperplasia
secondary to hepatitis C virus with portal hypertension now status post transjugular intrahepatic
portosystemic shunt.
TWENTY-FOUR-HOUR EVENTS: The patient underwent transjugular intrahepatic portosystemic
shunt placement yesterday per the Interventional Radiology report. Portal venous pressures prior
to transjugular intrahepatic portosystemic shunt placement were 32 mmHg. There were
successful creation of a transjugular intrahepatic portosystemic shunt with placement of a
covered stent, 8.2 cm in length and 10 mm in diameter. Post transjugular intrahepatic
portosystemic shunt, the mean main portal vein pressure was 12 mmHg, mid stent 11 mmHg,
upper portion of stent 10 mmHg. A venogram performed after stent deployment and balloon
dilatation showed adequate flow through the stent. The patient was monitored in the Intensive
Care Unit overnight and did well. His hematocrit was stable, and he showed no signs of hepatic
encephalopathy. He complains this morning of some nausea, well controlled on Zofran and
abdominal pain, as well as neck pain at the site of his Cordis line that is well controlled with
Norco. The patient has had no vomiting. Denies any hematemesis, melena, or hematochezia,
and denies any infusion or change in his concentration.
MEDICATIONS: Include Cipro 750 mg by mouth weekly, Lexapro 10 mg by mouth daily, Protonix
40 mg by mouth daily, Megace daily, multivitamins daily.
PAST MEDICAL, SOCIAL AND FAMILY HISTORY: Unchanged.
REVIEW OF SYSTEMS: The patient denies any chest pain or shortness of breath. Review of
systems is negative except for as noted above.
PHYSICAL EXAMINATION: T-max is 37.5, T-current 37.1, blood pressure 100/50, heart rate 100
to 110, respirations 17, saturating 97 to 100% on room air. He had 1.8 L in and 2.4 L out. In
general, he is a cachectic-appearing male lying comfortably in bed. HEENT exam shows
anicteric sclerae and moist mucous membranes. Oropharynx clear. Neck is supple with a right
internal jugular Cordis in place. The lungs are clear to auscultation bilaterally. Cardiovascular
exam is tachycardic and regular without any murmurs, rubs or gallops. Abdominal exam has
positive bowel sounds, soft, distended, nontender. Extremities show no edema. Skin has no new
rashes. Neurologic is alert and oriented with no evidence of asterixis.
LABORATORY DATA: White count of 5.7, hematocrit of 27.5, platelets are 187, INR is 1.3.
Sodium 143, potassium 3.9, chloride 96, bicarbonate 32, BUN 11, creatinine 0.9, glucose 108.
Total bilirubin is 1.3, AST 43, ALT 33, alkaline phosphatase 258.
MICROBIOLOGY DATA: April 14 ascites no growth to date. April 13 Clostridium difficile is
negative. April 13 cytomegalovirus is negative.
IMPRESSION: This is a 36-year-old male with human immunodeficiency virus and portal
hypertension secondary nodular regenerative hyperplasia from hepatitis C virus, who is now
status post transjugular intrahepatic portosystemic shunt for refractory ascites. His active
problems include:
1. Portal hypertension secondary to nodular regenerative hyperplasia, now status post
transjugular intrahepatic portosystemic shunt.
2. Refractory ascites secondary to portal hypertension.
3. Esophageal and gastric varices status post band ligation with no current symptoms of
gastrointestinal bleeding.
4. Abdominal pain and back pain secondary to ascites, improved on the current regimen of
Norco.
5. Human immunodeficiency virus infection currently on HAART.
6. Nausea.
PLAN:
1. We will get an ultrasound today to assess his transjugular intrahepatic portosystemic shunt.
2. The patient will be completing his course of Mucomyst and bicarbonate.
3. We will be starting therapy with lactulose. Although the patient has normal liver function, he is
still at risk of hepatic encephalopathy secondary to shunting.
4. We will be restarting diuretics of spironolactone 300 mg daily and Lasix 120 daily, and following
his sodium and urine output closely.
5. If his ultrasound is normal, we will discontinue the Cordis and the patient can be transferred to
the floor.
6. The patient's pain is currently well controlled on Norco and this appears to be the appropriate
regimen for him given his mental status is the best we have seen it in house.
This patient was seen and discussed in Liver Transplant rounds.
Shergill Sample 2:
CHIEF COMPLAINT: Tylenol overdose with fulminant hepatic failure and cerebral edema.
TWENTY-FOUR-HOUR EVENTS: No acute events. The patient received 1 dose of Lasix.
Encourage urine output and maintain the patient with overall negative fluid balance. Zosyn was
discontinued. Head CT yesterday showed decreased cerebral edema.
CURRENT MEDICATIONS: Include Zosyn, Colace, Keppra, senna, mannitol, fluconazole, LacriLube artificial tears and Prevacid.
PAST MEDICAL, SOCIAL, AND FAMILY HISTORY: Unchanged.
REVIEW OF SYSTEMS: The patient is unable as he is intubated and unarousable.
PHYSICAL EXAMINATION: Temperature current with active warming had a T-max of 35.1,
systolic blood pressure to 130 with diastolic 50 to 60, heart rate 52 to 71, central venous pressure
14 to 18, respirations assist control, FIO2 of 40%, rate 24 to 48, saturating 98 to 100%. Total in
2.9 L, total out 3.0 L. In general, the patient is intubated and unresponsive lying in bed. On
neurologic examination, she does not respond to voice. She has no withdrawal, no gag. Pupils
are equal, 2 mm bilaterally. HEENT exam show icteric sclerae. Nasogastric feeding tube is in
place. Endotracheal tube is in place. Chest has coarse breath sounds bilaterally, no wheezing.
Cardiovascular exam has regular rate and rhythm; no murmurs, rubs or gallops. On abdominal
exam, hypoactive bowel sounds, soft, mildly distended. Extremities have bilateral lower extremity
edema. Genitourinary exam shows Foley bag in place, Foley catheter in place. The skin has no
rashes.
MICROBIOLOGY DATA: Blood cultures times 3 from 4/17 pending. Urine cultures from 4/17
pending. Blood cultures times 4 from April 14 no growth to date. Urine cultures from April 14
negative. Mini-bronchoalveolar lavage from April14 no growth to date. The only positive culture
is April 12 mini-bronchoalveolar lavage with greater than 10,000 Candida albicans.
IMPRESSION: This is a 39-year-old female with a toxic Tylenol ingestion resulting in fulminant
hepatic failure, complicated by marked cerebral edema. Her liver enzymes have improved
indicating recovering liver synthetic function. However, her mental status remains concerning
despite CT scans indicating improved cerebral edema. She remains critical in the Intensive Care
Unit with the following issues:
1. Fulminant hepatic failure secondary to Tylenol overdose.
2. Cerebral edema.
3. Encephalopathy.
4. History of seizure disorder.
5. Candida albicans in mini-bronchoalveolar lavage.
6. Persistent fluid overload responding to diuretic therapy.
PLAN:
1. Neurologically, the patient continues to have an overall poor prognosis given no improvement
in her neurological status. Recent CT scans are reassuring for increased cerebral edema, but
this has resulted in no clinical improvement. She continues to be managed with mannitol as her
serum osmolalities permit. We will be monitoring her pentobarbital levels with daily urine
toxicology and once the urine toxicology is negative, we will send a pentobarbital level to verify
that it is undetectable.
2. Pulmonary: The patient has continued pulmonary vascular congestion, although she has
improved oxygenation. We will continue diuresis.
3. Cardiovascular: We will continue to support her blood pressure as needed. If possible, we will
wean dopamine if tolerated.
4. Gastrointestinal: Fulminant hepatic failure. The patient has had recovery of her hepatic
synthetic function. We will continue to monitor liver function tests given that she has a slight
increase in her total bilirubin today.
5. Hematologic: The patient's hematocrit has remained relatively stable and without any signs or
symptoms of gastrointestinal bleeding.
6. Infectious Disease: We will be discontinuing vancomycin and we will reculture the patient
tomorrow after she has been off antibiotics for approximately 24 hours. We will continue
fluconazole for the Candida albicans and her mini-bronchoalveolar lavage. A Clostridium difficile
is pending.
7. Renal: We will be giving the patient Lasix as needed to keep her fluid status overall negative.
8. Endocrine: The patient had a blood sugar of 70 this morning and we will be starting the D5
drip for this low blood sugar. It is concerning, given that she is on tube feeds at goal that she has
this low blood sugar level. Her hepatic synthetic function is recovered, so it is unlikely this is
related to ongoing liver disease. It is possible that this may be a reflection of ongoing infection,
which we will monitor her more closely.
9. Nutrition: Tube feeds are at goal.
Overall, the patient's prognosis remains quite guarded.
Kristina Rosbe, MD #43215:
POSTOPERATIVE CHECK: The patient is afebrile with stable vital signs and room air saturation
of 98%. She has had minimal oral feeds at this point. Physical exam reveals no active bleeding
and moderate uvular edema.
She was noted to have a rash in the Recovery Room felt to be related to several doses of
fentanyl. She had had a dose of intravenous ampicillin in the operating room, but this was 3 to 4
hours prior to development of the rash, so it was felt to be less likely related. The rash is
currently gone.
IMPRESSION AND PLAN: Stable postoperative course. She is admitted for airway monitoring,
pain control, and we will encourage oral intake.
Rosbe Sample 2:
POSTOPERATIVE DAY 1
The patient has been afebrile with stable vital signs overnight. She had an oxygen saturation of
98 to 100% room air. Oral intake has been 240 cc.
Physical exam revealed no active bleeding and mild edema.
She has had no oral intake this morning and her last pain medication was at 8 o'clock last night.
I will continue to encourage oral intake and if this improves, she most likely can be discharged
today on 10 days of antibiotics and pain medication. Her father was told of the possible suspicion
of an allergy to fentanyl and he was not able to state whether she had had amoxicillin in the past
without problems but she has had another dose of intravenous antibiotics overnight without any
development of rash. She currently has no rash.
She is also being followed by the Transplant and Pediatric Gastrointestinal teams as well as the
General Pediatrics team and we appreciate their input.
Chris Freise, MD # 51763:
The patient is on postoperative day 1 after orthotopic liver transplantation. He was surprisingly
stable overnight after a very long and difficult operation. He is responding somewhat, although
he is, for the most part, sedated. He is on the ventilator at 60% FIO2 with reasonable blood gas.
He had 6500 in, 4500 out; his T-max was 38.8, blood pressure is currently good on a little bit of
Neo-Synephrine. His Jackson-Pratt drains are putting out serosanguineous to sanguineous fluid.
The abdomen is quite soft. The dressings are clean and dry. He does have some peripheral
edema. His white count is 2.6, hematocrit 22, and he is receiving 3 units of blood for this;
creatinine is 2.1, AST 767, alkaline phosphatase 32, bilirubin 4.8 and INR is 1.6 on a fresh frozen
plasma drip.
Currently he is on CellCept 1500 b.i.d. and a prednisone taper. He remains on broad-spectrum
antibiotics with meropenem and fluconazole. No new culture information is back. Drains were
placed in the cavity in the lower abdomen that appeared to have some infected fluid. We will
continue to give him blood products, as needed through the day. It appears that he has liver
function based on his INR and his blood gases and hopefully the slight ooze that he has in his
abdomen will dissipate and we can begin to plan on weaning.
He should remain on antibiotics for at least another 2 weeks.
Freise Sample 2:
He had some more problems overnight with lower blood pressure and some blood product
requirement. He has had required some pressors this morning, as well. He did have a slight
bump in his hematocrit after receiving 2 units of blood, but is back down. We plan on obtaining
an ultrasound today, but I suspect he has developed some bleeding in his abdominal cavity. He
had 48,000 in, 47,000 out with the CVVH. His T-max was 37.2 and he remains on relatively
modest ventilator settings. Pulse is running 63 to 108; blood pressure is currently 120/60, CVP
running 6 to 10. The abdomen is fairly distended, a bit more tight than yesterday, but not terribly
tense. We did take down his wound VAC and carefully examined his wound. There is not really
much fluid coming through the mesh, nor does it look like there is a big hematoma just under the
mesh. The wound otherwise looks quite clean. He is edematous. White count is 23.9,
hematocrit is 20, AST is greater than 2600, and alkaline phosphatase is greater than 1700.
Bilirubin is 18.2, INR is 2.0. BUN is 21, potassium 4.2.
The plan is to obtain an ultrasound today as I suspect they will find a hematoma and this needs to
be drained at some point, however, with his enzymes again shooting up, I want to make sure that
he is not going into full-blown liver failure before taking him off to the operating room. If his
numbers stabilize somewhat and we can correct his coagulation panel, I think it would be prudent
to plan on an exploration in the next day or 2 assuming he continues to have evidence of blood in
his peritoneal cavity. I again had the discussion with the family informing them of this step back.
They understand the gravity of the situation. We will continue aggressive therapy. I would like to
switch him on his antibiotics on the chance that this may represent a septic episode. Cultures
have been drawn and we would like to get him on aztreonam and caspofungin if we can get
infectious disease's permission. He is currently on linezolid. Again, he remains critically ill in the
intensive care unit.
Peter Stock, MD #58033:
The patient continues in very critical shape related to acute respiratory distress syndrome. He
remains intubated, however, while we are beginning to wean him from the ventilator. Of
significant concern are the cardiac findings, which include a large left ventricle with thrombus.
We have asked our Infectious Disease consultants to weight in on the infection. He has had
nothing grow out from bronchoscopies at the old hospital. It is unclear if this could be pancreatitis
based on his higher amylase and lipase, and evidence of acute respiratory distress syndrome.
For this reason, we decided to stop any pancreatitis type drugs including CellCept and the
antiretroviral regimen in order to prevent development of resistance. We are going hold all
antiretroviral agents.
The most significant concern of course relates to his heart. He had clearly had a major cardiac
event resulting in a thrombus with decrease in left ventricular function. We are going to have him
assessed by Cardiology. His kidney function fortunately has improved dramatically, having gone
from 1.9 down to 1.2. He is on an extubation trial; however, we remain concerned about the work
he will have to do if he does get extubated. His amylase today was 780 and his lipase 152; both
represent higher levels. His hematocrit has been stable at 30.
For immunosuppression, we currently have him on 75 mg of Neoral by mouth twice daily and
Solu-Medrol 60 mg a day on a gradual taper. It is felt that the Solu-Medrol is beneficial in terms
of his acute respiratory distress syndrome. If there is not significant improvement, we may have
to stop the Neoral because of concerns for overall immunosuppression.
Stock Sample 2:
The patient is now postoperative day number 1 following combined pancreas and kidney
transplant. His postoperative course has been relatively uncomplicated from the point of view of
his organs; however, he has significant pain. On further questioning, it turns out that he has been
taking around 6 Vicodin a day for his neuropathic pain.
Today, he is afebrile with a blood pressure of 134/80. His saturations are 94% on 4 L nasal
cannula. His lungs are clear to auscultation with poor inspiratory effort. His surgical incision is
dry and intact. His serum amylase is 306. His serum creatinine is 10.8 down to 10.4. His
hematocrit is stable at 35.5. He continues to have a relatively poor urine output and for that
reason, we obtained and ultrasound, which is completely normal. We will maintain him on
nothing by mouth status and intravenous maintenance fluids until the return of his gut function.
He will remain on broad spectrum antibiotic coverage until we have final cultures. We will
prophylax against cytomegalovirus with Valcyte and Pneumocystis carinii with Septra.
For immunosuppression, he is receiving induction with Thymoglobulin. Continue him on CellCept
1 gm b.i.d. and Solu-Medrol on the standard post pancreas transplant regimen. We are
somewhat hesitant to give him a steroid-free regimen as he is African-American and we have had
a high incidence of rejection in this group.
For this reason, we may maintain him on a prednisone, CellCept and Prograf regimen.
Rev. 05/23/10