Clinical Notes

The writing of daily clinical notes – An example.

Provisional Diagnosis: DM, HPT, Acute STEMI

Day1: Pt was given Tenectaplase. Responded well – reperfusion successful. Vital signs BP 120/76mm Hg. Pulse regular 75/min. No signs of cardiac failure. Diabetic control not good – monitoring shows frequently above 10mmol/L. Blood urea noted to be high but serum creatinine normal - ? due to prerenal AKI. Urine output to be monitored.

Day 2: Pain free. No complaints. BP and pulse remain normal. No signs of heart failure. Urine output good. RP report awaited. Changes made to his diabetic treatment – His OHA has been stopped and he is on biphasic insulin twice daily. Capillary blood glucose at 6am was 8.2mmol/L. ECG today – no new changes.

Day 3: Pt has fever. Temp 38 deg C. Has cough and minimal sputum. Few creps detected in left lung posteriorly - ? pneumonia. ECG no new changes. Pulse BP stable. Diabetic control satisfactory. X-ray chest will be taken today. Renal profile is normal – urea back to normal.

Day 4: He has pneumonia – x-ray chest showed opacity in the left lung. Treating empirically with Augmentin. Temperature settling. Cardiac condition stable. BP, Pulse ok. Metformin restarted for diabetes. Insulin being continued.

Day 5: Pt feels well. Afebrile. Cough less. Chest auscultation less creps now. No evidence of heart failure. Pulse 68/min. BP 130/78mm Hg. Will be discharged today. ECG to be seen before discharge. Last plasma glucose 7.8mmol/L (before breakfast).

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