Inpatient Urology Progress Note

Daily Progress Note

"Date of Service:" 05/14/2024

"Patient:" Robert Harrison

"DOB:" 08/22/1956

"MRN#:" 78429103

Surgery: Robotic-assisted laparoscopic radical prostatectomy (RALP) on 05/13/2024, POD 1

Synopsis

This is a 67-year-old male admitted following an uncomplicated robotic-assisted laparoscopic radical prostatectomy for Gleason 3+4=7 prostate adenocarcinoma. He is progressing well on the postoperative pathway.

Interval History

No acute events overnight. Patient ambulated twice in the hallway with nursing assistance and tolerated clear liquids without nausea or emesis.

Subjective

Patient reports mild incisional soreness and slight bladder spasms, stating "I feel like I need to urinate even though the tube is in." Pain is well-controlled on oral regimen. Passing flatus, no BM yet. Denies SOB, chest pain, or calf tenderness.

Objective

• Vital signs, last 24h: Tmax 37.1 °C, HR 68-82 bpm, BP 124/76-138/84 mmHg, SpO2 98 % on RA, RR 14-16 /min
• Intake and Output:
  • Intake: 1,850 mL (PO 650 mL, IV 1,200 mL)
  • Output: 1,620 mL
• Drains:
  • Foley catheter: 18 Fr council tip in place, draining pink-tinged urine without clots, 1,550 mL/24h
  • JP drain: Pelvic JP to bulb suction, serosanguinous output, 70 mL/24h

Physical Exam

• General: Alert, NAD, resting comfortably in bed
• CV: RRR, normal S1/S2
• Pulm: CTAB, no wheezes or rales
• Abd: Soft, mildly distended, appropriately tender at port sites. Laparoscopic incisions clean, dry, intact with Dermabond. BS+
• GU: Foley secured to right thigh, meatus clear
• Ext: WWP, no lower extremity edema or calf tenderness, SCDs in place

Medications

"Scheduled Meds:" paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q8H, docusate sodium (Colace®) 100 mg PO BID, enoxaparin (Lovenox®) 40 mg SC Q24H, tamsulosin (Flomax®) 0.4 mg PO QHS

"Continuous Infusions:" lactated Ringer's 75 mL/h IV

"PRN Meds:" oxycodone (Roxicodone®) 5 mg PO Q4H PRN moderate pain, oxybutynin (Ditropan®) 5 mg PO Q8H PRN bladder spasms, ondansetron (Zofran®) 4 mg IV Q6H PRN nausea

Labs, Imaging, and Other Studies

"• Laboratory: All recent labs have been reviewed. Pertinent labs include" WBC 9.8 x 10^3/µL, Hgb 12.4 g/dL (baseline 14.1 g/dL), Plt 210 x 10^3/µL, Na 138 mmol/L, K 4.1 mmol/L, Cr 0.9 mg/dL, JP fluid Cr 0.9 mg/dL (consistent with serum, rules out urine leak)

Assessment/Plan

Robert Harrison is a 67-year-old male patient of Dr. Vance status post RALP, now POD 1. He is hemodynamically stable, passing flatus, and ready for JP drain removal and discharge today.

1. Malignant neoplasm of prostate (ICD-10: C61)
   • Plan: Discontinue pelvic JP drain today as output is < 100 mL/24h and fluid Cr is normal. Discharge home with 18 Fr Foley catheter in place; return to clinic on 05/21/2024 for voiding trial and pathology review.
   • Counseling: Reviewed catheter care instructions, leg bag vs. night bag usage, and expected mild hematuria around the catheter with activity. Advised to return for fever, inability to drain urine, or severe abdominal pain.
2. Acute postoperative pain (ICD-10: G89.18)
   • Plan: Transition to PO analgesia; prescribe paracetamol 1,000 mg PO Q8H, ibuprofen 400 mg PO Q8H PRN, and oxycodone 5 mg PO Q6H PRN (#10 tabs) at discharge.
   • Counseling: Discussed multimodal pain control and minimizing narcotic use to prevent postoperative ileus and constipation.
3. Urologic or postsurgical issue 3, 4, 5, etc. Postoperative bladder spasm (ICD-10: N32.89)
   • Plan: Prescribe oxybutynin 5 mg PO TID PRN bladder spasms; instruct patient to stop 24 hours prior to scheduled voiding trial.
   • Counseling: Reassured patient that sensation of urinary urgency is normal due to the Foley balloon irritating the trigone.
4. Fluids (always include a plan for IV fluids)
   • Heplock IV fluids now that patient is tolerating adequate PO intake.
5. Electrolytes (always include a plan for electrolytes)
   • Electrolytes WNL; replete electrolytes PRN.
6. Diet (always include a nutrition plan)
   • Advance to regular diet today.
7. Prophylaxis (always include a prophylaxis plan)
   • Enoxaparin 40 mg SC daily while inpatient, SCDs when in bed, and frequent ambulation.
8. Disposition (always include disposition)
   • Discharge home today once tolerating regular breakfast and after JP drain removal.

Orders

• Discontinue IV lactated Ringer's
• Remove pelvic JP drain
• Advance diet to regular
• Discharge prescription: oxycodone 5 mg PO Q6H PRN (#10), oxybutynin 5 mg PO TID PRN (#20), docusate sodium 100 mg PO BID (#30)

"Signed by:"

Marcus Sterling, MD, PGY-5 Urology Chief Resident

“Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit before this encounter. All questions were answered. The patient understands that they may decline the use of AI-assisted tools.”