Urology Inpatient Follow-Up Rounds Template

DAILY PROGRESS NOTE
SYNOPSIS:
This is a 65-year-old male who had a radical prostatectomy two days ago. He is recuperating well without significant complications and is currently under observation for urinary retention and infection.
24 HOUR EVENTS:
The patient experienced mild hematuria overnight, which has since resolved. Recent laboratory results indicate a slight decrease in hemoglobin levels, but they remain within acceptable limits.
SUBJECTIVE:
"I feel a bit tired, but the pain is manageable," the patient reports. He also mentions, "I am concerned about the blood in my urine last night."
OBJECTIVE:
"Vital signs last 24h:" Temp: 37.2°C, HR: 78 bpm, BP: 120/80 mmHg, SpO2: 98%, RR: 16
"Intake and Output:" Intake: 2000 mL, Output: 1800 mL over the last 24 hours
"Drains:" Foley catheter in place, draining clear yellow urine
PHYSICAL EXAM:
Abdomen soft, non-tender, surgical site clean and dry, no signs of infection.
LABS, IMAGING, AND OTHER STUDIES:
"Radiology: Recent imaging studies have been reviewed and are notable for no new findings."
"Laboratory: All recent labs have been reviewed. Pertinent labs include hemoglobin at 12.5 g/dL, WBC count at 8.0 x10^9/L."
"Microbiology data: All recent micro results have been reviewed. Pertinent micro results include negative urine culture."
ASSESSMENT AND PLAN:
65-year-old male with post-prostatectomy recovery.
1. Urinary retention
Assessment: The patient is at risk for urinary retention post-surgery.
Plan:
- Continue monitoring urine output via Foley catheter.
- Consider trial of voiding once hematuria resolves.
- Educate patient on signs of urinary retention.
2. Risk of infection
Assessment: The patient is at risk for infection due to recent surgery.
Plan:
- Continue prophylactic antibiotics as per protocol.
- Monitor for signs of infection, including fever and increased WBC count.
- Reinforce wound care instructions with the patient.
3. Pain management
Assessment: The patient reports manageable pain levels.
Plan:
- Continue current analgesic regimen.
- Assess pain levels regularly and adjust medication as needed.
- Discuss non-pharmacological pain management techniques with the patient.