DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Acute-on-chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease exacerbation.
2. Chronic obstructive pulmonary disease exacerbation.
3. Upper respiratory tract infection.
4. Uncontrolled diabetes.
5. Chronic pain syndrome.
6. Hypertension.
BRIEF HISTORY: The patient is a (XX)-year-old Hispanic female who has a history remarkable for chronic pain syndrome due to chronic fibromyalgia, spinal stenosis, and multiple back surgeries. The patient also has a history of hypertension and diabetes type 2, insulin required; hypothyroidism; and temporal arteritis, on chronic steroid use. The patient has a history of COPD, home oxygen dependent. The patient was admitted on MM/DD/YYYY complaining of progressive shortness of breath, cough, and congestion. The patient was found with significant CO2 retention on ABG as well as bilateral wheezing on physical examination that was thought to be related to acute COPD exacerbation. The patient was admitted with this diagnosis initially.
HOSPITAL COURSE: After being admitted in the hospital, the patient was started on intensive nebulizer treatment as well as IV Decadron, oxygen 2 liters via nasal cannula, as well as IV antibiotics among multiple other medications the patient is taking at home. The next day of admission, the patient was significantly doing much better, still complaining of generalized pain syndrome, and the patient was willing to do some adjustment of her pain therapy.
The patient developed significant uncontrolled diabetes with sugar levels above 400; this was felt to be steroids related. The patient was eventually tapered down from Decadron and placed on p.o. 25 units of prednisone, eventually resolving the process of uncontrolled diabetes. The patient’s x-ray did not suggest any underlying infiltrates or pneumonia, but a mildly elevated BNP was found. The patient responded well to IV Lasix therapy with good urine production.
At the time of discharge, the patient was feeling significantly better. She denies any shortness of breath, chest pain, palpitations, headaches, and the pain syndrome was significantly controlled after increased dose of Duragesic patch of 75 mcg. At the time of discharge, the patient was hemodynamically stable.
PLAN: The patient has been discharged to home in stable condition. We have called this patient’s drug store to refill all the medications needed for her. The patient is to return to the office for full evaluation and followup.
