DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
PRINCIPAL DIAGNOSES:
1. Community-acquired pneumonia.
2. Urinary tract infection.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female with a past medical history of hypertension, diagnosed 11 years ago, who presented to the emergency department with complaints of fever, chills, night sweats, shortness of breath, and cough productive of brownish sputum for the past three days.
PAST MEDICAL HISTORY: Bronchitis; pneumonia, last year, treated as an inpatient; and hypertension.
PREVIOUS HOSPITALIZATION: Last year for pneumonia.
ALLERGIES: The patient denied any known drug allergies.
CURRENT MEDICATIONS: The patient was taking Norvasc.
SOCIAL HISTORY: The patient admits to smoking half a pack per day. No substance abuse. No alcohol abuse. As per the patient, she was tested for HIV last year, and it was negative, and the patient refused to be tested again. The patient lives with her father.
REVIEW OF SYSTEMS: Positive for fever, night sweats, weight loss, decreased appetite, nausea, vomiting, coughing, and right-sided pleuritic chest pain.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature was 99.2 degrees, pulse was 124, respirations 18, and blood pressure was 92/68. LUNGS: On clinical examination, the lungs had decreased breath sounds in the right lower lung field. ABDOMEN: Soft. No organomegaly.
LABORATORY AND DIAGNOSTIC DATA: The patient’s white count was 19,800, hemoglobin was 12.4, and platelets 296,000. Sodium was 127, bicarbonate was 24, chloride was 92, potassium was 4, BUN was 36, creatinine was 1.7, and glucose was 110. The patient also had 1+ ketones, 3+ blood in the urine. Chest x-ray showed right middle lobe infiltrate.
HOSPITAL COURSE: The patient was admitted for right middle lobe pneumonia as well as renal insufficiency. The patient was started on Levaquin. Blood cultures were done. The patient also had urine toxicology, which came out to be positive for methadone with drug screen and opiates. The patient’s ABG was 7.46, 33, and 17.6. This was the first time that the patient came to this hospital. The patient was subsequently discharged on p.o. Levaquin with plan to follow up in medical clinic.
PRINCIPAL PROCEDURE PERFORMED: Chest x-ray.
FOLLOWUP: The patient was asked to follow up in the medical clinic.
