S. Whitfield

Ridgeview Memorial Hospital Inpatient Progress Note — Hospital Medicine er aes el a Ee ee patient: S. Whitfield MRN: 74102-C9 DOB: --/--/1949 (76 yo F) Admit date: Day 1 POS: 21 - Inpatient Attending: T. Nakashima, MD History of present illness: 76-year-old female with history of CKD stage 3 (documented baseline creatinine ‘around 1.5 per outpatient chart, not confirmed this admission") and prior aspiration events, brought from assisted living facility for lethargy, decreased oral intake, and low-grade fever over 2 days. Vitals and initial labs: Temp 38.1C, HR 98, BP 104/62, RR 20, SpO2 91% on room air. WBC 14.6, creatinine 2.0 mg/dL (no prior value in this record for comparison). Lactate 1.7 mmol/L. Chest x-ray showed right lower lobe opacity. Urinalysis with moderate bacteria, few WBC. Assessment on admission: Admitting note states ‘concern for sepsis, favor pneumonia as source, possible urinary contribution cannot be excluded.’ No explicit statement identifying which source is being treated as the principal problem. Hospital course: Started on empiric ceftriaxone and azithromycin for presumed community-acquired pneumonia. No vasopressors required at any point; blood pressure remained stable throughout admission. No repeat creatinine obtained after hospital day 1, so trend during treatment is not documented in this record. Blood cultures resulted no growth at 48 hours. Oxygen requirement improved from 3L NC to room air by day 3. Assessment and plan: Community-acquired pneumonia versus urosepsis, clinically improved. Acute kidney injury versus chronic baseline, not distinguished in this admission due to absence of repeat labs. Discharged hospital day 4 on oral antibiotics; recommend nephrology follow-up for renal function reassessment as outpatient.