ADMITTING DIAGNOSIS: Exacerbation of chronic obstructive pulmonary disease.
DISCHARGE DIAGNOSES:
1. Exacerbation of chronic obstructive pulmonary disease.
2. Acute sinusitis.
3. Mild congestive heart failure.
4. Bronchospasm.
5. Coronary artery disease.
6. Anxiety disorder.
7. Hyponatremia.
8. Depression.
BRIEF HISTORY: This patient is a (XX)-year-old female who had a presentation whereby she became somewhat short of breath and had a great deal of production of somewhat whitish sputum. She had increased fatigue and increased cough. Secondary to the worsening of her symptoms, the patient was brought to the emergency room as she started to have shortness of breath at rest.
The patient was evaluated and stabilized with regard to her breathing and CT scan was done showing a right maxillary sinusitis. She was admitted to the hospital for exacerbation of her chronic obstructive pulmonary disease in the setting of having a sinusitis.
PERTINENT PHYSICAL FINDINGS: General: The patient was alert and appeared somewhat tired. HEENT: No acute findings noted to exam. Heart: Regular rhythm with S1 and S2 distinct. Lungs: Appeared with diffuse wheezes and rhonchi were noted in a diffuse fashion as well. Extremities: Good range of motion and there was no evidence of clubbing or cyanosis to evaluation.
HOSPITAL COURSE: The patient was admitted with a presentation of exacerbation of chronic obstructive pulmonary disease. The patient was given intravenous antibiotic therapy, bronchodilator therapy via nebulizer and also intravenous corticosteroid therapy. She had serial EKGs and cardiac enzymes done with the presentation of mild congestive heart failure to rule out any acute myocardial event. The patient’s cardiac enzymes proved negative. The EKGs were not diagnostic, except for mild left ventricular hypertrophy. Chest x-ray did not show any acute pulmonary process. She was watched closely with regard to her breathing status.
The patient also was monitored closely with regard to her response to the bronchodilator therapy. Antibiotics were adjusted according to the patient’s allergy status. Pulmonary medicine consultation was obtained, and it was felt that the patient would be able to continue with the current medication regimen of using corticosteroid therapy, IV antibiotics and bronchodilator therapy via nebulizer. The patient also had 2D echocardiogram study done to evaluate her cardiac status. The echocardiogram showed the presentation for aortic valve being mildly thickened. The left ventricular systolic and diastolic dimensions appeared to be normal. The overall ejection fraction was about 51%. The patient had trace to mild mitral regurgitation and mild to moderate tricuspid regurgitation.
Overall conclusion was that the patient’s left ventricular ejection fraction was at 51%, it being reasonable. She continued with aggressive pulmonary measures regarding her overall status, and the patient did not have any other adverse symptomatology during the remainder of her hospitalization stay. On MM/DD/YYYY, it was deemed that the patient was medically stable for discharge, as she had shown definite improvement regarding her status.
DISCHARGE DIET: The patient will be on a low-salt, low-fat diet.
DISCHARGE MEDICATIONS: Omega-3 fish oil 2 capsules b.i.d., Vytorin 10/20 one daily, lorazepam 1 mg t.i.d. , isosorbide mononitrate ER 30 mg daily, Lexapro 20 mg daily, metoprolol 25 mg b.i.d., Plavix 75 mg daily, Tessalon 200 mg b.i.d., benazepril 10 mg daily, Medrol Dosepak used as directed, Combivent inhaler 2 puffs t.i.d. , Ceftin 500 mg b.i.d. for 1 week.
FOLLOWUP: The patient would be discharged and has recommendation to keep her appointment that has already been established.
