723989226
OMH
6410178
996067
3/30/1999 12:00:00 AM
Discharge Summary
Signed
DIS
Report Status :
Signed
DISCHARGE SUMMARY
NAME :
NETSHUFFSCARVTRACE , RIRA
UNIT NUMBER :
005-27-20
ADMISSION DATE :
03/30/1999
DISCHARGE DATE :
09/16/2006
PRINCIPAL DIAGNOSIS :
Severe chronic obstructive pulmonary disease .
Respiratory failure .
Congestive heart failure .
Right lower lobe pneumonia .
Atonic bladder with suprapubic catheter .
Anxiety .
Coronary artery disease .
History of colon cancer status post hemicolectomy .
HISTORY OF PRESENT ILLNESS :
This is a 76 year old white male with severe chronic obstructive pulmonary disease who has had several recent admissions to Oaksgekesser/ Memorial Hospital for respiratory insuffiencey most often secondary to pneumonia .
He was most recently discharged from Oaksgekesser/ Memorial Hospital on 03/06/99 and was then transferred to Linghs County Medical Center from which he was discharged on 03/20/99 .
The patient was doing relatively at home until one day prior to admission he complained discomfort over a suprapubic catheter area .
The patient had missed his usual monthly change of his suprapubic catheter and felt discomfort and noticed some blood at the site of the catheter .
The patient was brought to the Emergency Room one day prior to admission where he was evaluated by Urology and had his catheter changed .
The patient at that time noted slight shortness of breath but was sent home anyway .
On the day of admission the patient noticed increasing shortness of breath .
The patient was noted to be confused and to be disoriented toward the end of the day after complaining of shortness of breath for most of the day .
The patient denies any recent upper respiratory infections , no fevers , no chills , no change in cough , sputum .
He also denies any chest pain .
No orthopnea .
No paroxysmal nocturnal dyspnea .
The patient had been taking his usual medications and using his nasal oxygen at home .
By the time the patient arrived at the Oaksgekesser/ Memorial Hospital Emergency Room he was in moderate respiratory distress .
His initial blood gases on 40% 02 was P02 102 , PC02 115 , PH 7.11 .
The patient was given respiratory therapy in the way of nebulizer treatments in the Oaksgekesser/ Memorial Hospital Emergency Room because of a longstanding desire by patient and family to refrain from intubation to be considered Do Not Resuscitate .
The patient was not intubated .
However he was transferred to the Medical Intensive Care Unit where he received continuous respiratory therapy in theway of Albuterol nebulizers as well as nasal oxygen , intravenous steroids and intravenous antibiotics .
A chest x-ray in the Oaksgekesser/ Memorial Hospital Emergency Room showed new changes on his chest x-ray on top of his usual severe bilateral emphysema_____ with scarring in both lungs .
There were new air space opacifications in the left apex and the right lower lobe .
These were thought to be consistent either with pneumonia or asymmetric pulmonary edema .
PAST MEDICAL HISTORY :
Associated medical problems include :
1. Atonic bladder with a suprapubic tube .
2. Anxiety .
3. Coronary artery disease with a history of angina in the distant past .
4. History of colon cancer with a colectomy in the past .
MEDICATIONS ON ADMISSION :
1. Ativan 1 mg po twice a day .
2. Trusopt 1 gtt left eye three times a day .
3. Xalatan 0.005% one gtt left eye qhs .
4. Brimonidine 1 gtt left eye three times a day .
5. Combivent 3 puffs four times per day .
6. Aerobid three puffs twice a day .
7. Sorbitol 30 cc every other day .
PHYSICAL EXAMINATION :
He was an elderly frail gentleman in moderate respiratory distress .
He had a blood pressure 110/70 , heart rate 110 beats per minute and regular , respiratory rate 25 .
He was in moderate respiratory distress .
His temperature was 98F .
He had a normal head , eyes , ears , nose and throat exam .
Neck exam revealed no jugular venous distention and no masses .
Lung exam revealed decreased breath sounds as well as crackles in the bases .
There were no wheezes or rhonchi .
Heart exam revealed a soft S1 and S2 , no murmur was heard , no S3 .
Abdomen was soft , nontender with no masses palpable .
Rectal exam was unremarkable with stool heme negative .
Neurological exam revealed an alert and oriented x 3 elderly male .
He moved all extremities .
Deep tendon reflexes were symmetrical in all extremities .
LABORATORY AND RADIOLOGIC DATA :
Sodium 148 , potassium 3.4 , glucose 174 , P02 102 , PC02 115 , PH 7.11 on 40% 02 .
Blood urea nitrogen 11 , creatinine .6 , uric acid 3.0 , alkaline phosphatase 78 , creatinine phosphokinase isoenzymes too low , hematocrit 41 , white blood cell count 11.6 .
Urine analysis showed 20-50 white blood cells and 3-5 red blood cells .
Electrocardiogram showed sinus tachycardia at a rate of 123 beats per minute compared to previous electrocardiogram of 1/29 there were no significant changes .
HOSPITAL COURSE :
The patient was stabilized in the Medical Intensive Care Unit .
He stayed in the unit for about one day .
During that period of time he received nebulizer treatments with Albuterol .
He was also started on intravenous Ticarcillin for possible gram negative pneumonia .
He was diuresed with intravenous Lasix to which he responded with at lease a 2L urine output on the first day and 1.5L the second day .
After one day in the Medical Intensive Care Unit the patient was stable enough to go to the floor where he continued the rest of his treatment .
This consisted of continued nebulizer treatments as well as intravenous antibiotics and intravenous Solu-Medrol .
As the patient 's diuresis continued his respiratory status improved .
A chest x-ray showed clearing of the opacities in the chest x-ray that were consistent with pulmonary edema because he continued to have some abnormality in the right lower lobe .
The patient was continued on antibiotics for possible pneumonia .
The antibiotic chosen was Levaquin 500 mg 1 tab per day .
This was started on 4/2/99 and should be continued for ten days .
The Ticarcillin was stopped after two days when it was felt that he did not have a serious pneumonia .
The patient 's respiratory status continued to improve but towards the last 2-3 days of his hospitalization the amount of improvement was minimal .
It was felt that his respiratory status has been maximally treated by then .
The patient 's major improvement came after the first two days with brisk diuresis with Lasix .
While in the Oaksgekesser/ Memorial Hospital the patient on 4/4/99 complained of mild epigastric discomfort because he was put in Cimetidine while in the Intensive Care Unit for prophylaxis against peptic ulcer disease .
The patient was upgraded to Prilosec 20 mg per day for possible treatment of gastritis or gastroesophageal reflux disease .
The patient did have any nausea , vomiting or evidence of gastrointestinal bleeding .
The patient 's abdominal pain should be followed over the next week or so in case it does not respond to Prilosec .
While in Oaksgekesser/ Memorial Hospital the patient was never able to get out of bed and walk independently .
It is hoped that when he is transferred to a rehab facility that he will continue with physical therapy to regain his strength and regain independence in activities of daily living .
Discussion with the family regarding the possibility of sending him to a nursing home was entertained however the family strongly refused to allow him to go a nursing home .
They wanted the patient to return to his home after a stay at a rehab facility .
CONDITION ON DISCHARGE :
The patient 's respiratory status was stable .
I think his breathing was as good as to be expected with the amount of severe chronic obstructive pulmonary disease he had .
He needed to go to a rehab facility for continued respiratory therapy and for Physical Therapy to increase his muscle strength .
MEDICATIONS ON DISCHARGE :
1. Albuterol 2.5 mg in 2.5 normal saline q4h .
2. Heparin 5000 units subcutaneously twice a day .
3. Ativan .5 mg twice a day .
4. Nasal oxygen 3L per minute .
5. Levaquin 500 mg per day to be continued until 4/12/99 .
6. Lasix 40 mg per day .
7. Prednisone 40 mg per day to be tapered over two weeks .
8. Xalatan eyedrops 1 gtt in left eye per day .
9. Alphagan 1 gtt in left eye three times a day .
10. Trusopt 1gtt in left eye three times a day .
11. Prilosec 20 mg per day .
FOLLOWUP :
The patient should have follow up with his primary care physician Dr. Rod Linkeboltshieltrus at the TRE 453 about one week after discharge from rehab facility .
The telephone number at his office is 236-4518 .
ROD END , M.D.
TR :
lh
DD :
04/05/1999
TD :
04/05/1999 3:06
Pcc :
ROD END , M.D.
C.R.TRYGLO HOSPITAL OF STAT