Hospital day 4, 0800. A 74-year-old client admitted with community-acquired pneumonia is receiving ceftriaxone and azithromycin; she took ciprofloxacin for a urinary tract infection two months ago. At home she lives alone, walks with a cane, and is continent. Since 0400 she has passed six watery stools with mild abdominal cramping and no visible blood. She has not received a laxative or stool softener in the past 48 hours. Yesterday she walked to the bathroom independently with her cane; she now asks for a bedpan because she feels unsafe walking and is lightheaded when she stands. Respiratory: cough with scant white sputum and fewer crackles than on admission; SpO2 96 percent on room air. Vital signs: temperature 37.9 C after 48 hours afebrile, heart rate 96, up from 74 yesterday, and BP 118/72, within her usual range. Laboratory: WBC 14.2, up from 9.1 x 10^9/L yesterday, with neutrophilia; procalcitonin down to 0.3 ng/mL from 1.8 on admission; creatinine 1.1 mg/dL (baseline 1.0); and lactate 1.4 mmol/L. She is alert and oriented times three.
住院第4天，0800。一位74歲個案因社區型肺炎入院，正在接受ceftriaxone和azithromycin治療；她兩個月前曾因泌尿道感染服用ciprofloxacin。她獨自居住在家，使用拐杖行走，且大小便控制良好。自0400以來，她已排出六次水樣便，伴有輕微腹部絞痛，無可見血。過去48小時內她沒有服用瀉藥或軟便劑。昨天她可以獨立使用拐杖走到浴室；她現在要求使用便盆，因為她走路不安全感，站立時會頭暈。呼吸道：少量白色痰液咳嗽，囉音比入院時少；室內空氣下血氧飽和度96%。生命徵象：退燒48小時後體溫37.9°C，昨天心率96，從74上升，血壓118/72，在她平常的範圍內。實驗室：昨天白血球14.2，從9.1上升 x 10^9/L，伴有嗜中性球增多；降鈣素原從入院時的1.8降至0.3 ng/mL；肌酸酐1.1 mg/dL（基準值1.0）；以及乳酸1.4 mmol/L。她意識清楚，對人、時、地皆有概念。