Microsoft Word - Example of Assesssment Write Up



1130300901700The following is an example of a possible write up of an assessment based on problems. It is typical of the write ups you will see on the General Medicine service. You can see how each problem is addressed. The thinking of the physician (the actual assessment) is present if applicable and not otherwise obvious and combined with a brief plan.00The following is an example of a possible write up of an assessment based on problems. It is typical of the write ups you will see on the General Medicine service. You can see how each problem is addressed. The thinking of the physician (the actual assessment) is present if applicable and not otherwise obvious and combined with a brief plan.11303001973580For background information: 70 year old female, history of DM, CHF, obesity with associated sleep apnea, anemia, chronic renal failure being evaluated and prepared for dialysis with fistula placement, who now comes into the hospital with worsening shortness of breath and chest pains.00For background information: 70 year old female, history of DM, CHF, obesity with associated sleep apnea, anemia, chronic renal failure being evaluated and prepared for dialysis with fistula placement, who now comes into the hospital with worsening shortness of breath and chest pains.11303002867025SOB/ Dyspnea on exertion:00SOB/ Dyspnea on exertion:13589003046095?00?15875003054350On exam the patient is fluid overloaded. Symptoms are improving with00On exam the patient is fluid overloaded. Symptoms are improving with15875003232785preload reduction, using nitro and LasixPossible pneumonia, given antibiotics based on chest x‐ray, but the patient does not have a fever, cough, nor sputum production. Will consider holding antibiotics as his presentation seems most consistent with fluid overload Consider etiology of symptoms to be ACS (acute coronary syndrome) Cardiac enzymes negative x3, EKG unremarkable and similar to priors. Plan echocardiogram.Worsening renal function is also contributing to fluid overload. Increase lasix dose.00preload reduction, using nitro and LasixPossible pneumonia, given antibiotics based on chest x‐ray, but the patient does not have a fever, cough, nor sputum production. Will consider holding antibiotics as his presentation seems most consistent with fluid overload Consider etiology of symptoms to be ACS (acute coronary syndrome) Cardiac enzymes negative x3, EKG unremarkable and similar to priors. Plan echocardiogram.Worsening renal function is also contributing to fluid overload. Increase lasix dose.13589003411855?00?13589003956050?00?13589004500880?00?11303005044440Chronic Renal Failure:Worsening renal function, heart failure may be contributing factor.00Chronic Renal Failure:Worsening renal function, heart failure may be contributing factor.13589005410200?00?15875005419090Follow urine electrolytes, BUN, Creatinine, r/o obstruction00Follow urine electrolytes, BUN, Creatinine, r/o obstruction11303005775960Anemia:Hx of iron deficiency00Anemia:Hx of iron deficiency13589006141720??00??15875006150610No bleeding Continue observation00No bleeding Continue observation11303006694170DM:??00DM:??15875006882130Continue glargine 50 units BID and follow inpatient protocol Check Hgb A1c00Continue glargine 50 units BID and follow inpatient protocol Check Hgb A1c11303007425690F/E/N???00F/E/N???15875007613650No iv fluid at this time Follow electrolytes Diabetic diet00No iv fluid at this time Follow electrolytes Diabetic diet11303008345170Prophylaxis:No indication for proton pump inhibitor at this time00Prophylaxis:No indication for proton pump inhibitor at this time13589008710930?00?15875008719185Heparin 5000 Units subcutaneously tid00Heparin 5000 Units subcutaneously tid11303009076690DispositionAdmit to General Medicine Service; FULL CODE00DispositionAdmit to General Medicine Service; FULL CODE1130300901700Another possibility:00Another possibility:11303001259205Assessment: This 70 year old female with a history of DM, CHF chronic renal failure is now admitted for increasing shortness of breath, most likely due to fluid overload based on exam and preliminary laboratory data and she already appears to be improving with preload reduction using nitro and lasix. Pneumonia is less likely and so we will hold antibiotics. Her worsening renal failure could either be a contributing factor to her increased symptoms of CHF or more likely a result of this worsening CHF. Her diabetes is stable, with blood sugars falling in range of recommendations.00Assessment: This 70 year old female with a history of DM, CHF chronic renal failure is now admitted for increasing shortness of breath, most likely due to fluid overload based on exam and preliminary laboratory data and she already appears to be improving with preload reduction using nitro and lasix. Pneumonia is less likely and so we will hold antibiotics. Her worsening renal failure could either be a contributing factor to her increased symptoms of CHF or more likely a result of this worsening CHF. Her diabetes is stable, with blood sugars falling in range of recommendations.11303002867025Plan:Continue iv lasix and nitroglycerin over next 24 hours then switch to oral medication only. We will monitor her renal function, intake and output, and follow her blood sugars. No IV fluids at this time.Also we will continue to educate the patient about the importance of compliance with both medications and diet and will have dietician see patient today.00Plan:Continue iv lasix and nitroglycerin over next 24 hours then switch to oral medication only. We will monitor her renal function, intake and output, and follow her blood sugars. No IV fluids at this time.Also we will continue to educate the patient about the importance of compliance with both medications and diet and will have dietician see patient today. ................
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