ICD-10 Discharge Summary Date of Admission 1/31 Date of Discharge:2.3 Discharge Diagnosis: Right lower lobe pneumonia due

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ICD-10 Discharge Summary

Date of Admission 1/31 Date of Discharge:2.3

Discharge Diagnosis: Right lower lobe pneumonia due togram-negative bacteria, resistant to erythromycin.

Admission History: This is a 56-year-oldinsulin-requiring diabetic female whose diabetes is out of controlwhom we have been following for hypertension, degenerative jointdisease, aortic stenosis and diabetic retinopathy. Over the pastthree days she has noted increased cough and chest congestion witha fever of approximately 102 degrees. She was found to have a rightlower lobe infiltrate and was started on therapy with erythromycin.Despite initial therapy, the patient’s clinical status has worsenedover the past 24 hours.

Course in Hospital: Patient was admitted with thediagnosis of right lower lobe pneumonia. She was begun onintravenous ceftriaxone. Because of difficulties with venousaccess, patient was switched to intramuscular ceftriaxone on herthird hospital day.

By ? the patient was afebrile and her cough haddiminished. Her blood pressure was well controlled at140/74.

Instructions on Discharge: Follow up with me by phone inthree days and in my office in two weeks. Repeat chest x-ray to bedone then.

Medications:

Calan SR 180mg b.i.d.
Zestril 20mg PO q.a.m.
NPH Insulin, 30 units, sub q., a.m.
Levoquin 500mg PO daily x10 days
Celebrex 100 mg PO b.i.d.

History and Physical Examination

Admitted: 1/31

Reason for admission: Physical examination on admissionrevealed a well-developed, acutely ill-appearing blackfemale.

History of present Illness: A 56-year old diabeticfollowed for hypertension and diabetic retinopathy. Over the pastthree days she has noted increased cough and chest congestion witha fever of approximately 102 degrees. She was found to have a rightlower lobe infiltrate and was begun on therapy with erythromycin.Despite initial therapy, the patient’s clinical status worsenedover the past 24 hours and hospitalization wasrecommended.

Past medical history: Hypertension,degenerative joint disease in both knees, and moderate aorticstenosis

Allergies: Dust

Chronic Medications: Calan SR 180mg b.i.d., Insulin(NPH), Zestril 20mg PO daily, Celebrex 100 mg POb.i.d.

Family History: Notable for hypertension inmother

Social History: Noncontributory

Physical Examination:

General Appearance: The patient is awell-developed black female in moderate distress.
Vital signs: T 102, P 80, R 16, BP 150/80
Skin: Warm and dry
Heent: Significant for mildly inflamed mucous membranes.Retinopathy evident in both eyes.
Neck: Supple. Symmetrical with no bruits.
Lungs: Coarse rhonchi bilaterally, right greaterthan left
Heart: Regular rate and rhythm, positive S1,positive III/VI SEM
Abdomen: Soft, nontender, no mass

Genitalia: Deferred

Rectal: Deferred

Extremities: No edema

Neurologic: Normal

Laboratory Data:

EKG: NSR, widespread ST-T wave abnormalities, LVhypertrophy
CBC: Hgb 13, Hct 38, WBC 12.8
Glucose: 281
Urinalysis: Unremarkable
Sputum: Gram stain - a few WBCs, moderate gram-negativerods

Impression:

Right lower lobe pneumonia possibly due to gram-negativebacteria
Diabetes mellitus on insulin-uncontrolled
Hypertension-stable
Degenerative joint disease-stable
Moderate aortic stenosis

Plan: Admit, IV antibiotics for pneumonia. Monitor bloodsugars.

Progress Note

Date Note

1/31 Patient admitted for cough associated withincreased temperature with chest x-ray indicated of pneumonia. Willobtain sputum culture and begin on ceftriaxone. Will monitor bloodpressure and blood sugars. Will use sliding scale to bring bloodsugar into control. Patient with recent echocardiogram asoutpatient that showed stable aortic stenosis.

2/1 The patient is responding well. Will requestdiabetic education nurse to meet with ehr and set up an appointmentfor classes following this admission.

2/2 Sputum culture reveals gram-negative bacteria assuspected. Patient/s temperature is down. Patient is restingcomfortably. Blood sugar better.

2/ 3 Blood sugar with increasing control today. Theimportance of appropriate diet emphasized. Will discharge with p.o.antibiotics.

Physical Orders

Date Note

1/31 Admit to 3 South

Dx: Pneumonia

Please give ceftriaxone 1 g q 8 hours IV

ADA diet

CBC and SMA

Calan SR 50 mg in a.m. with orange juice

Zestril 2 in a.m.

Celebrex 100 mg po BID

Accu-Chek before meals and before bedtime

Chest x-ray

Sliding scale for insulin as follows:

-Below 120 give 4 units of regular

-120-200 give 6 units of regular insulin

-200-300 five 8 units of regular insulin

-Above 300, call physician

2/1 Change insulin to 40 NPH units sq in a/m/today

Consult diabtic nurse to see patient and set up classesfollowing admission.

2/2 Continue insulin to 40 NPH units sq in a.m.today.

2/2 D/C IV and switch to ceftriaxone 1 g IM q.24hrs

2/3 Discharge to home.

Microbiology

Date Test Type

1/31 Source

Site:

GRAM STAIN RESULTS: Sputum

CULTURE RESULTS: Slight WBCs, Slight Epis

Many gram-negative rods

Sl. gram-negative diplococci

Sl. gram-positive cocci in clusters

SUSCEPTIBILITY: S

AMPICILLIN S

CEFAZOLIN S

CEFOTAXIME S

CEFTRIAXONE S

CEFUROXIME S

CEPHALOTHIN S

CIPROFLOXACIN S

ERYTHROMYCIN R

GENTAMICIN S

OXACILLIN S

PENICILLIN S

PIPERACILLIN S

TETRACYCLINE S

TOBRAMYCIN S

TRIMETH/SULF S

VANCOMYCIN S

S= SUSCEPTIBLE

R= RESISTANT,I= INTERMEDIATE,M= MODERATELYSUSCEP

Date: 1/31

History Diagnosis: Pneumonia

Findings: There is slight overexpansion of the lungs.The pulmonary vasculature is normal. The heart is not enlarged.There is lower lobe infiltrate in the right lung.

Impression: Right lower lobepneumonia

EKG

Date: 1/31. Diagnosis:Pneumonia

Interpretation: EKG: NSR, widespread ST-T waveabnormalities, LV hypertrophy

Chemistry

Date: 1/31

Specimen	Results	Normal Values
GLUC	281 H	70-110
CREAT	0.67	0.5-1.5
NA	142	136-146
K	4.8	3.5-5.5
CL	108	95-110
CO2	29	24-32
CA	9.5	8.4-10.5
PHOS	3.8	2.5-4.4
MG	2.8	1.6-3.0
T BILI	1.0	0.2-1.2
D BILI	0.3	0.0-0.5
PROTEIN	6.5	6.0-8.0
ALBUMIN	5.1	5.0-5.5
AST	38	0-40
ALT	54	30-65
GGT	50	15-85
LD	180	100-190
ALK PHOS	102	50-136
URIC ACID	4.5	2.2-7.7
CHOL	89	0-200
TRIG	101	10-160

Urinalysis

Date: 1/31

Test	Results	Ref Range
SP GRAVITY	1.007	1.005-1.035
PH	7.0	5-7
PROT	NEG	NEG
GLUC	NEG	NEG
KETONES	NEG	NEG
BILI	NEG	NEG
BLOOD	NEG	NEG
LEU EST	NEG	NEG
NITRATES	NEG	NEG
RED SUBS	NEG	NEG

HEMATOLOGY

DATE: 1/31

Specimen	Results	Normal Values
WBC	12.8 H	4.3-11.0
RBC	5.5	4.5-5.9
HBG	13.0 L	13.5-17.5
HCT	38 L	41-52
MCV	90	80-100
MCHC	41	31-57
PLT	251	150-450