General Surgery Progress Note
Subjective: Patient had a difficult overnight. She reports significant difficulty sleeping, with strange dreams about having forgotten something terribly urgent. She complains of a lack of food, and of the unreasonableness of her daily waking hour, 3:15 AM. No acute issues. Denies shortness of breath, chest pain, nausea and vomiting. Upon questioning, she reluctantly reports that she is passing flatus and making urine.
Objective: Vitals: Temperature 37, Pulse 70, Blood Pressure 100/70, Respiratory Rate 11, Oxygen Saturation 100% on room air.
Ins/Outs: None recorded. Nursing staff reports very little water intake, as the hospital's tap water tastes unbelievably bad.
Labs: None ordered.
Exam:
General: Thin, somewhat undernourished female. Has not bathed properly in two days. Awake, alert, oriented to self, place, and time.
Cardiovascular: Regular heart rhythm, no murmurs appreciated. Somewhat tachycardic, particularly when confronted with an attending surgeon on staff rounds.
Respiratory: Lungs clear to auscultation bilaterally.
Abdomen: Soft, non-tender, non-distended. Three scars from laparascopic appendectomy in 2006 appreciable. Bowel sounds hyperactive in all four quadrants, most likely due to persistent hunger.
Extremities: Trace edema in feet from hours of standing. Bruise on left knee from being nailed by automatic OR doors.
Assessment: 26 year-old female whose name no one remembers, with an extremely interesting history that no one cares about, is status post 5 weeks of a general surgery rotation. Doing well, all things considered.
Plan:-See the patient through a week of three exams, including a shelf exam, which she must pass at all costs. Increased dosage of caffeine may be necessary, adjust as tolerated.
-Feed the patient. Goddammit, feed this patient.
-Due to a combination of anxiety and adjustment to duty hours, patient is willfully depriving herself of sleep. Efforts must be made to correct this deficiency, as it represents a danger to herself and others. Wine protocol shall be implemented if necessary.
-As often as necessary, please remind patient that she will be released soon. Any day now...
-Just as soon as she passes her shelf exam.
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