HISTORY
Patient is a 77-year-old female who states for the last 3
days, she has had a history of frequency, dysuria and taken AZO over the
counter. Today she started having
violent chills, fever, altered mental status and her husband just brought her
to the emergency room because he was concerned and she was talking out of her head. She is kind of confused which is very unlike
Mrs. Sweatt. She is normally very
sharp. She is a patient of my partner,
Dr. Brummett. She recalls my name. She knows her history, but just says she has
just been so sick she cannot think, but she got some Tylenol here and she is
starting to break her fever and has some chills.
PAST MEDICAL HISTORY
She has had a bladder tack in the past by Dr. Hunt. Otherwise she says she has had no surgeries
besides Dr. Meichner has taken care of her for diverticulosis along with reflux
and she has had to have dilatations and some of this obtained from her and old
records.
ALLERGIES
She has no known allergies.
MEDICATIONS
1. She is on
Prevacid 1 a day.
2. A blood
pressure pill. She says a low-dose water
pill, but she is not sure of the name of it.
She has been on it for the last 3 years.
FAMILY HISTORY
Noncontributory.
SOCIAL HISTORY
She does not smoke.
She does not drink. She had 2
children, one died secondary to MI. She
has been married almost 57 years and she is normally very healthy. She has been admitted to the hospital once
before she said for a kidney infection, but she said that was a few years back.
OBJECTIVE
GENERAL: When I see
patient, she is an elderly female who is shaking and said her stomach is
hurting and I think it is her side as well.
She said it just feels like she is still having burning as well. She has hardly been able to drink or eat much
at all over the last 24 hours.
ENT: Oropharynx is
very dry. Her TMs are clear.
NECK: I cannot detect
any carotid bruits.
CHEST: She has
bilateral breath sounds, decreased in the bases, but she cannot take deep
breaths because it hurts her side.
CARDIAC: Regular rate
and rhythm with the rate right at the 80s to 90s.
ABDOMEN: She has
positive bowel sounds, but is tender in both quadrants in the CVA regions but
also in the abdomen.
EXTREMITIES: She has
nonpitting edema.
PELVIC: Did not do a
pelvic exam at this time secondary to distress.
DATA
Urinalysis was very cloudy.
She had positive nitrite, 3+ leukocyte.
She had greater than 100 white cells per high-power field, 11 to 20 red
cells. Other laboratory data: Her brain natriuretic peptide was 304. Blood gas showed a pH of 7.5, pCO2 of 30, pO2
of 71. EKG showed a normal sinus
rhythm. White count was 27,000 with a
left shift. She has 88 segs, 6 bands. H and H normal at 11.7 and 35.8. Troponin was unremarkable. Amylase was normal. Lipase was normal. Magnesium was 2.1. Chest x-ray showed a little haziness around
the pericardiac silhouette. This could
be due to shaking because I do not see any infiltrates or masses.
ADMISSION DIAGNOSES
1. Acute
pyelonephritis with probable sepsis.
2. History
of gastroesophageal reflux disease, status post dilatations.
3. Altered
mental status secondary to No. 1.
4. Dehydration.
5. History
of hypertension for 3 years.
PLAN
At this time, she is getting her IV antibiotics as I am
dictating of IV Levaquin 750. Blood
cultures and urine cultures have been obtained.
Going to start her on IV fluids, normal saline at 150 mL an hour. Will hold her diuretic. Will start her on Protonix p.o. with her
chronic reflux problem. Will repeat labs
in the a.m. Give her electrolytes to
correct some which they should. Have
discussed this with her and her husband, who are very thankful. She also got a CT scan of head while in the
ER and it was normal.
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