Medicine progress note template

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Date
Time:
MS3 Progress Note (medicine)
S:
Interval history?
Pain?
Appetite?
NOW THINK: what is happening with my patient? Anything special I need to think about/look for on exam? Anything I
don’t understand about what is happening with them?
O: VS: Tm
I/O:
Tc
P
R
BP
Sat
on
Gen:
HEENT:
Lungs:
C/V:
Abd:
Extremities:
Neuro:
Antibiotics?
Pain meds?
DVT prophylaxis?
Diet:
Labs:
Cultures
Imaging
A/P
Day
of
GI prophylaxis?
Fluids?
Rate?
Hypercalcemia Etiologies - CHIMPANZEES
C - Calcium overdose (don’t usually mention this one)
H - Hyperparathyroidism, Hyperthyroidism, Hypothyroidism, familial Hypercalcemic hypocalciuria
I - Immobility
M - Multiple myeloma
P – Paget’s disease
A – Addison’s disease
N – Neoplasms:
- metastasis to bones and
- hypercalcemia of malignancy (a paraneoplastic syndrome)
Z – Zollinger-Ellison syndrome
E – Excess vitamin A
E – Excess vitamin D
S – Sarcoidosis
Indications for Acute Hemodialysis - AEIOU
A – Acidosis (unable to be managed medically)
E – Electrolytes (typically hyperkalemia, unable to be managed medically)
I – Intoxication (methanol, ethylene glycol, lithium)
O – Overload (fluid overload unresponsive to diuretics)
U – Uremia (symptomatic)
Causes of delirium – MOVE, STUPID
Metabolic
Oxygen
Vascular
Endocrine/Electrolyte
Seizures
Tumor/Trauma/Temperature
Uremia
Psychogenic
Infection/Intoxication
Drugs/Degenerative disease
Causes of metabolic acidosis with an anion gap – MUD PILES
M – methanol
U – uremia
D – diabetic ketoacidosis
P – para-aldehyde
I – Isoniazid, iron, inborn errors in metabolism
L – lactic acidosis
E – ethanol, ethylene glycol
S – salicylates
Treatment of Acute MI – MONA
M - morphine
O - oxygen
N - nitrates
A - aspirin
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