Will start diuresis with furosemide 40 mg daily. Also resume losartan 25 mg, carvedilol 12.5 mg BID. Consult cardiology today. - Furosemide 40 mg daily - Losartan 25 mg daily - Carvedilol 12.5 mg BID - Cardiology consult This also helps making sure that your note is updated, even when you copy-forward 5. Cut the fluff: As the time passes most problems will get more defined. The acute hypoxic respiratory failure differentiates into pulmonary embolism or heart failure for instance. I always remove the reasoning from the first day's note as the problem is solidified. For example: # Altered mental status Most likely due to hepatic encephalopathy given cirrhosis and lactulose non-adherence. Possible opioid use given unclear history and pinpoint pupils. Less likely stroke given normal CT, electrolyte derangements given normal CMP, etc. Couple days pass, UDS comes back negative and the patient is responding to lactulose. You should delete the reasoning above and update the problem. Below are two versions:
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