---
# System prepended metadata

title: Ward Round Note Example

---

# Ward Round Note Example
## LIH Ward Round 12 June 2019 :hospital: 
|Name:|Ms IM Anonymous |Date admitted: |xx/xx/xxxx|
|-----|-|--|-|
|Number: |123-321-1234|Consultant:|Dr J Bloggs|
|GP:|Dr Nicedoc|Date discharged:||

## Social preamble
- 62y retired schoolteacher
- Rockwood Frailty Scale 2wks prior to admission: **3**

## Unresolved problems
- Enlarged transplanted liver, malaise, possible weight loss, nausea

## Established diagnoses & comorbidities
- Primary biliary cirrhosis with liver transplant
- Hb 98, MCV 100, Plt 120, anaemia, Prothrombin time 20
- Acute Kidney Injury: Cre 127 from 76; eGFR 40 from >60
- Vitamin D deficiency
- Type 2 diabetes mellitus using insulin; HbA1C 38
- Mild aortic stenosis with regurgitation
- Previous haemorrhage fro oesophageal varices
- Thrombosis of inferior vena cava
- Previous acute renal failure, tracheostomy
- Back pain after a fall with multiple old thoraco-lumbar spinal fractures
- Ex-smoker

## Notable results
## Vital signs
|Resps|O2 sats|FiO2|BP|Pulse|AVPU|Temp|NEWS|
|-|-|-|-|-|-|-|-|
| | | |-/-| | | | |

## Today's Progress Note
- DATE: 2019-06-12 Time started: 13:34
- Transplant team phone number is xxx xxx xxxx
- Progress since last review: Improving or Stable or Deteriorating

## Today's Plan:
- Actions:
- New tests agreed & requested

## Quality & Safety Check
- [ ] Nurse present during review? 

