Acute bacterial meningitis Progress Note Template
Date: [DATE]
Patient: [PATIENT NAME]
MRN: [MEDICAL RECORD NUMBER]
Attending Physician: [DOCTOR NAME]
Subjective:
Present illness: Briefly summarize the patient’s current symptoms, including onset, duration, and severity. Note any specific concerns or progression of symptoms since admission.
Past medical history: Briefly mention any relevant past medical history, including chronic illnesses, recent infections, immunizations, and allergies.
Social history: Briefly mention any pertinent social factors, such as recent travel, living conditions, and exposures (e.g., daycare, close contact with someone with meningitis).
Objective:
Vital signs: Record current vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
Physical exam:
General: Note appearance of illness, level of alertness, and meningeal signs (e.g., nuchal rigidity, Kernig’s sign, Brudzinski’s sign).
HEENT (Head, Ears, Eyes, Nose, Throat): Look for fever, rash, bulging fontanelle (in infants), papilledema (swollen optic nerve), and signs of upper respiratory infection.
Neurologic: Assess mental status, cranial nerves, motor and sensory function, and reflexes.
Laboratory:
Mention results of relevant laboratory tests, including:
Complete blood count (CBC) with differential
Electrolytes
Blood cultures (blood drawn before antibiotics)
Lumbar puncture (cerebrospinal fluid analysis)
Imaging: Note any imaging studies performed (e.g., CT scan of the head) and significant findings.
Assessment:
Summarize the patient’s clinical presentation, incorporating findings from history, physical exam, and laboratory/imaging studies.
State the working diagnosis (e.g., acute bacterial meningitis) with a level of certainty (e.g., highly likely, possible).
Plan:
Outline the treatment plan, including:
Antibiotics – Specify the type, dose, and route of administration.
Supportive care – Mention management of fever, pain control, fluid resuscitation, and electrolyte balance.
Repeat laboratory testing – Indicate any planned follow-up tests to monitor response to treatment.
Neurologic monitoring – Mention need for monitoring of mental status and neurologic function.
Consultations – Indicate if consultation with specialists (e.g., infectious disease, neurology) is necessary.
Note: This is a template and specific details may vary depending on the individual patient and their clinical course.