Urinary tract infection site not specified Metabolic encephalopathy Osteoporosis unspecified Unspecified essential hypertension Other persistent mental disorders due to conditions classified elsewhere Diaphragmatic hernia without mention of obstruction or gangrene Hypothermia not associated with low environmental temperature
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Morphine
 
Attending: ___.
 
Chief Complaint:
Altered mental status
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
___ yo F with PMH of HTN, osteoporosis, hip fracture living at 
assisted living (___) ___ yrs. Family noticed while 
visiting today that she was disoriented, speech was slurred, 
could not remember whether pt had breakfast. Pt had been dosing 
off and becoming more somnolent intermittently last few days. By 
the time ambulance arrived, patient was really unable to 
communicate with other people but still recognized her son. No 
reported fevers at ___. 
.  
In ED VS were T98 HR 64 132/72 18 100% RA. Labs were drawn, UA 
showed trace leuk esterase, pos nitrate, ___ WBCs and many 
bacteria. WBC of 10.5. Given IV ciprofloxacin for presumed UTI. 
.  
On the floor, the patient is somnolent, is oriented to person, 
knows that she's in the hospital but not which one. Not oriented 
to time. Patient is difficult to understand and falls asleep 
multiple times during the interview. Denies dysuria, urinary 
frequency, abdominal pain or fevers at home. 
 
Past Medical History:
(per OMR, unable to obtain from the patient)
Memory loss
Osteoporosis with multiple fractures (hip, vertebral, 
ulna/radius)
HTN
Diverticulitis
partial SBO
Basal Cell Ca s/p resection
s/p cataracts
s/p TAH/BSO/appy

 
Social History:
___
Family History:
unable to obtain from the patient
 
Physical Exam:
ADMISSION EXAM:
VS: 93.4 ax, 95.5 rectal; 156/96, 87 18 98%RA
General: somnolent, eyes closed, opens eyes to voice and 
mumbles. difficult to understand. Cachetic.
HEENT: small irregular pupils on both sides, minimally reactive. 
MM dry. 
Cardiovascular: RRR. Normal S1/S2, S4. No murmurs/gallops/rubs.  

Pulmonary: CTAB, no wheezes/rales. 
Abd: Soft, NT/ND, +BS. No HSM.  
Extremities: cool to palpation, no edema. 
Skin: No rash, ecchymosis, or lesions.  
Neuro/Psych: Unable to test as patient does not follow commands. 
pt with general contractures
 
Pertinent Results:
___ 11:30AM BLOOD WBC-10.5# RBC-3.61* Hgb-12.1 Hct-35.2* 
MCV-97 MCH-33.5* MCHC-34.4 RDW-12.9 Plt ___
___ 11:30AM BLOOD Neuts-90.1* Lymphs-4.1* Monos-5.0 Eos-0.5 
Baso-0.2
___ 11:30AM BLOOD Glucose-116* UreaN-28* Creat-0.9 Na-139 
K-4.5 Cl-102 HCO3-27 AnGap-15
___ 11:42AM BLOOD Lactate-1.5
___ 12:50PM URINE Blood-TR Nitrite-POS Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-TR
___ 12:50PM URINE RBC->50 ___ Bacteri-MANY Yeast-NONE 
Epi-0
================================
IMAGING:
___ CXR: No acute intrathoracic process. Moderate-to-large 
hiatal hernia
as before.
================================
MICROBIOLOGY: 
___ URINE CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE 
NEGATIVE. >100,000 ORGANISMS/ML.
___ BCx: negative
 
Brief Hospital Course:
___ yo F with HTN and osteoporosis, living at ___ 
with increasing somnolence, lethargy and confusion in last few 
days, found to have UTI in the ED.
.
# UTI: UA with many RBCs, some WBC and bacteria. Patient was 
started on IV cipro in the ED. Cipro was continued in the 
hospital given patient's clinical improvement. 
.
# Hypothermia: initially concerning for sepsis, however, her 
other vital signs remained within normal limits. Patient was 
monitored with antibiotic treatment and her temperature 
improved. She remained afebrile throughout the hospital stay.
.
# AMS: though she does have underlying dementia, patient was 
reported to be more somnolent in days prior to admission, likely 
related to UTI. Her mental status improved with treatment of her 
UTI. At baseline, she is AOx1, only to self. She does know that 
she lives at ___, but could not say which hospital 
she was in or what year it is. 
.
# Osteoporosis: history of multiple fractures in the past. 
Patient was continued on her calcium and vitamin D in house. 
.
# HTN: Her antihypertensives were held initially given concern 
for sepsis and possible hypotension. Her blood pressure remained 
within normal limits and became elevated during the second 
hospital day, so she was restarted on home metoprolol. She will 
be discharged on home antihypertensive regimen. 
 
Medications on Admission:
Calcium + Vitamin D BID
Tylenol arthritis
Fosamax 70 mg 
metoprolol 25 BID
amlodipine 5 daily
multivitamin
aspirin 81
colace daily
 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for for pain/fevers.  
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a 
day.  
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

7. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H 
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
8. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) 
Tablet PO twice a day.  
9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Urinary Tract Infection

 
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
As you know, you were admitted to ___ for confusion. We 
performed a urine analysis which showed that you had a urinary 
tract infection. We treated you with antibiotics and your 
confusion resolved. When you go home, you will need to continue 
antibiotics.

These changes were made to your medications:
START ciprofloxacin 250 mg by mouth every day for 3 more days
 
Followup Instructions:
___

{'Altered mental status': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Somnolence': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Slurred speech': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Disorientation': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Difficulty communicating': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Recognition of son': ['Urinary tract infection', 'Metabolic encephalopathy'], 'Leukocyte esterase': ['Urinary tract infection'], 'Positive nitrate': ['Urinary tract infection'], 'White blood cell count': ['Urinary tract infection'], 'Bacteria in urine': ['Urinary tract infection'], 'Cachetic appearance': ['Osteoporosis'], 'Small irregular pupils': ['Metabolic encephalopathy'], 'Dry mucous membranes': ['Dehydration'], 'Cool extremities': ['Hypothermia not associated with low environmental temperature'], 'No edema': ['Unspecified essential hypertension'], 'Normal heart sounds': ['Unspecified essential hypertension'], 'No murmurs/gallops/rubs': ['Unspecified essential hypertension'], 'Soft abdomen': ['Diaphragmatic hernia without mention of obstruction or gangrene'], 'No hepatosplenomegaly': ['Diaphragmatic hernia without mention of obstruction or gangrene'], 'No rash/ecchymosis/lesions': ['Other persistent mental disorders due to conditions classified elsewhere']}