Ridgeview Memorial Hospital

Inpatient Progress Note — Hospital Medicine

Patient: J. Delgado MRN: 88213-A4 DOB: --/--/1967 (58 yo M) Admit date: Day 1 POS: 21 - Inpatient Attending: R. Castellano, MD History of present illness:

58-year-old male with no significant past medical history presented to the emergency department with 2 days of dysuria and fever. Alert and fully oriented throughout the emergency department visit and admission; no mental status change at any point.

Vitals and initial labs:

Temp 38.9C, HR 108, BP 88/54 (single reading on arrival, improved to 112/70 after 1 L crystalloid bolus), RR 20, SpO2 97% on room air. WBC 15.4, lactate 1.6 mmol/L. Urinalysis showed greater than 100 WBC/hpf with positive nitrites and leukocyte esterase. Blood cultures x2 drawn on admission.

Hospital course:

Received 1 L crystalloid bolus in the ED with prompt and sustained improvement in blood pressure; no further hypotensive episodes recorded during the remainder of the admission and no organ dysfunction identified on any system review. Repeat lactate at hour 6 was 1.2 mmol/L. Blood cultures resulted positive for Escherichia coli, matching urine

culture (E. coli greater than 100,000 CFU/mL). Empiric ceftriaxone narrowed to ciprofloxacin per sensitivities.

Assessment and plan:

Uncomplicated sepsis secondary to E. coli urosepsis, resolved with antibiotics and a single fluid bolus. No vasopressor support required at any point and no evidence of

organ dysfunction throughout admission. Discharged hospital day 5 on oral antibiotics with primary care follow-up scheduled.