Name: ………………………………………………….….……..

DOB: ………………………………. Gender: …………….

MRN: …………………………….. NOG: …………………
Adm. Date: …………………… Bed: …………….......
Physician: …………………………………………………..….
Coverage: ……………………………………………………...
Resident Admission Note
DATE: Thursday, September 17, 2020 TIME: 15:36 a9/p9
CHIEF COMPLAINT: High grade fever of 2 days duration
HISTORY: Case of 76 years old female known to HTN, DL not on statin , presented with 2 days history of high
grade fever reaching 39 associated with chills , responsive to antipyretics (Panadol), with myalgias and
generalized fatigue and decrease po intake, also reports urinary incontinence and urinary frequency , but no
dysuria, no flank pain. She reports chronic productive cough of whitish sputum that did not increase recently ,
she denies recent antibiotic use , no dyspnea, rhinorrhea or sore throat or nasal stuffiness, no nausea ,no
vomiting , no diarrhea ,no abdominal pain, no other complaint
Labs done as out showed positive urine analysis with high CRP :262
Travel history : none
Exposure to pets: none
Occupation: housewife

PMH: HTN
DL
PSH:None
Allergies: None
Medications:Exforge 160/5/12.5mg OD
Aspicot 100 OD
Concor 5 mg OD
SH: Smoker more than 40 pack year
ROS:
Constitutional: Denies weight loss
HENT:  Denies sore throat or ear pain
Respiratory: Denies shortness of breath
Cardiovascular: Denies chest pain, palpitations or swelling
GI: Denies abdominal pain, nausea, vomiting, or diarrhea. Denies melena, hematochezia
GU:  Denies dysuria, hematuria, flank pain
Neurologic: Denies headache, focal weakness or sensory changes

TEMPERATURE: 37,3 SPO2: 92% PULSE: 76 BP:99/52 HEIGHT: WEIGHT: 58

GENERAL APPEARANCE: Normal, not in distress

NEURO: Alert & oriented x 3, normal motor function, normal sensory function, no focal deficits noted.
HEENT/NECK: Norm cephalic, atraumatic, oropharynx moist, no oral exudates, Nose normal. Neck- normal range of motion
LUNGS/HEART: Normal heart rate, normal rhythm, Ejection systolic murmur 3/6 , no rubs, no gallops. GBAE , no added
sounds
ABDOMEN: Bowel sounds normal, Soft, no tenderness, no masses, no pulsatile masses.
GENITO-URINARY: No CVA tenderness
SKIN: Warm, dry, no erythema, no rash
OTHERS: No Lower limb edema

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MR F-10 Ed.7
 Name: ………………………………………………….….……..
Resident Admission Note (Continued) DOB: ………………………………. Gender: …………….
MRN: …………………………….. NOG: …………………
Adm. Date: …………………… Bed: …………….......
DIAGNOSTIC TESTS: Physician: …………………………………………………..….
Labs as out: WBC: 12.2 Neutro: 85% , Hb: 12.8, plts: 172, Na: 130 , K:3.5, cl:92 , Coverage:
CO2:28 CRP:……………………………………………………...
262
U/A: 8-10 WBC
2-4 RBCS
IMPRESSION: Case of 76 years old female known to HTN, DL, presented with 2 days history of high grade fever and
urinary symptoms with high crp:
R/o UTI
R/o Urosepsis /Bacteremia

MANAGEMENT PLAN: IV Hydration

Skip anti-Hypertensive meds and monitor BP
Start Ceftriaxone 2g OD
Follow up Urine + Blood cultures
Monitor vitals , fever
Follow clinically

RESIDENT NAME & SIGNATURE: Ali Dakroub PGY1 DATE 9/17/2020 TIME:15:36 a9/p9

ATTENDING NAME & SIGNATURE: DATE TIME

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MR F-10 Ed.7