Fever and confusion

Date: 2024-07-04

Admitting Physician: Dr. Emily Johnson, DO

Chief Complaint: Fever and confusion

HPI:

The patient is an 80-year-old female presenting with a 2-day history of fever and confusion. The patient has been disoriented and unable to perform daily activities. There is no history of recent travel or sick contacts.

ROS:

• General: Fever present.
• Neurological: Confusion, no focal deficits.
• Cardiovascular: No chest pain, no palpitations.
• Respiratory: No cough, no shortness of breath.

PFSH:

• Past Medical History: Type 2 diabetes, hypertension.
• Family History: No relevant family history.
• Social History: Lives alone, non-smoker, no alcohol use.

Physical Examination:

• Vital Signs: BP 110/70, HR 90, RR 20, Temp 101.2°F.
• Neurological: Disoriented to time and place, no focal neurological deficits.
• Cardiovascular: S1, S2 normal.
• Respiratory: Clear to auscultation bilaterally.
• Abdomen: Soft, non-tender.

MDM:

• Blood cultures pending.
• Urinalysis suggests urinary tract infection.
• Diagnosis: Urosepsis.

Plan:

• Admit to medical ward.
• Start broad-spectrum antibiotics.
• Monitor vitals and mental status.