Maria Ferreira 78 · Bed 12

Family: Ana Ferreira (daughter), Pedro Ferreira (son)

Today's chart note

DAILY PROGRESS NOTE · Internal Medicine, Ward 4B, Bed 12
Maria Ferreira, 78F · Day 4 of admission · Sat 26 Sep 2026

PROBLEMS
1. Community-acquired pneumonia, RLL (CURB-65 2): active, improving
2. Type 1 respiratory failure: resolved, weaned off O2 on day 3
3. Hyperglycaemia, HbA1c 7.9%: new, probable T2DM, not yet discussed with patient
4. Hypertension: chronic, controlled

FINDINGS (last 24h)
Afebrile >36h (Tmax 37.2). BP 132/78, HR 82, SpO2 95% on room air.
Alert and oriented, eating ~75% of meals, mobilising to chair with assistance.
Labs: CRP 48 mg/L (from 112), WCC 9.8 (from 15.2), creatinine 0.9, capillary glucose 180-240 mg/dL.
CXR: partial resolution of RLL consolidation.

PLAN
- CT thorax tomorrow (Sun 27/09) to exclude parapneumonic effusion
- If afebrile and CT clear: switch IV amoxicillin-clavulanate to oral on Mon 28/09
- Expected discharge Tue 29/09 if CT clear and clinically stable
- Discuss new diabetes diagnosis with patient at Monday ward round; refer to endocrinology

NURSING
- Bloods (FBC, CRP, U&E) at 07:00
- Capillary glucose QID, sliding-scale insulin per protocol
- Stop IV fluids if oral intake >1.5 L
- Mobilise with physio, falls precautions

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