Clinical note · #53
Hospital & observation
Patient Name: Sarah Williams
MRN: 54321876
Date of Admission: 09/20/2024
Date of Discharge: 09/25/2024
Attending Physician: Dr. Amanda Chen
Primary Diagnosis: Acute uncomplicated pyelonephritis
Secondary Diagnosis: None
Hospital Course:
Sarah Williams, a 32-year-old female, was admitted with fever and flank pain. Urinalysis revealed pyuria, and urine culture confirmed E. coli infection. She was treated with intravenous ceftriaxone, showing improvement by day 2, with resolution of fever and reduction in pain.
Final Physical Exam:
- Vitals: BP 118/76, HR 78, Temp 98.2°F
- Heart: Regular rate and rhythm
- Lungs: Clear to auscultation
- Abdomen: Non-tender, no rebound tenderness
Discharge Medications:
- Ciprofloxacin 500 mg orally twice daily for 5 days
- Ibuprofen 400 mg as needed for pain
Discharge Instructions:
- Complete the course of antibiotics
- Maintain hydration (at least 8 glasses of water daily)
- Return to hospital if fever or pain worsens
Follow-Up:
- Primary care follow-up in one week
Discharge Condition:
Stable, afebrile, tolerating oral fluids.
Discharge Time: 25 minutes
Disposition: Discharged home in stable condition.