Influenza with other respiratory manifestations Chronic obstructive asthma with (acute) exacerbation Obstructive chronic bronchitis with acute bronchitis Unspecified essential hypertension Coronary atherosclerosis of native coronary artery Esophageal reflux Other and unspecified hyperlipidemia Tobacco use disorder
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Fever, non-productive cough
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ yo F w/ HTN, CAD, COPD p/w fevers, non-productive cough, 
since ___. Pt said she was in her usual state of health until 
___ evening when she developed a cough producing ___ 
sputum.  She took some robitussin and went to bed.  She woke up 
the next morning and had general malaise, nasal congestion, 
intermittently productive cough.  She did not want to eat and 
had 4 episodes of water diarrhea and one episode of vomiting 
without nausea.  She denied fevers, chills or sweats at that 
time.  She called her PCP who prescribed ___ Z-pack.  Her symptoms 
persisted and she developed pain with coughing around her upper 
abdomen and lower chest.  Denies other joint or muscle pain.  
She went to see her PCP on the day of admission.  In her PCP's 
office was hypoxic on RA, here is 89% on RA. Has had flu vaccine 
this year and pneumovax last year. wheezy on exam, on 2L with o2 
sat mid-90s.  
.
In ED VS were afebrile 70 113/66 94%2L, On exam had wheezes with 
peak flow of 150 (no baseline), speaking in full sentences and 
no accessory muscle use, euvolemic and no ___ edema.  Flu screen 
not performed, CXR unremarkable compared to prior.  Given 
levoflox, nebs, pred 50 mg.

 
Past Medical History:
ASTHMA   
HYPERTENSION   
HYPERLIPIDEMIA   
HEADACHE   
OSTEOARTHRITIS   
ATYPICAL CHEST PAIN   
TOBACCO ABUSE   
ABNORMAL CHEST XRAY   
COPD  
 
Social History:
___
Family History:
Mother: ___, HTN  
Father: ___ CA  
Brother: CA?  
Brother: ___  

 
Physical ___:
On Admission:
VS: T:  , BP: 142/70, HR: 70, RR 20, O2 93% on RA (96% 2L)
GA: AOx3, pt with nasal cannula on in no respiratory distress
HEENT:  MMM. no LAD. no JVD. neck supple. 
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes, good inspiratory effort, but 
not great air movement, slightly prolonged expiratory phase.
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no noticeable rashes
Neuro/Psych: CNs II-XII intact
.
ON DISCHARGE:
VS: T:  , BP: 142/70, HR: 70, RR 20, O2 93% on RA (96% 2L)
GA: AOx3, pt with nasal cannula on in no respiratory distress
HEENT:  MMM. no LAD. no JVD. neck supple. 
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes, good inspiratory effort, but 
not great air movement, slightly prolonged expiratory phase.
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no noticeable rashes
Neuro/Psych: CNs II-XII intact
 
Pertinent Results:
LABS:
___ 03:26PM BLOOD WBC-4.9 RBC-4.25 Hgb-12.7 Hct-36.5 MCV-86 
MCH-30.0 MCHC-34.9 RDW-15.3 Plt ___
___ 06:50AM BLOOD WBC-8.2# RBC-4.03* Hgb-12.2 Hct-34.8* 
MCV-87 MCH-30.4 MCHC-35.1* RDW-15.3 Plt ___
___ 03:26PM BLOOD Glucose-123* UreaN-14 Creat-0.9 Na-136 
K-3.3 Cl-97 HCO3-31 AnGap-___ 06:50AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-139 
K-3.5 Cl-98 HCO3-30 AnGap-15
.
MICRO:
    **FINAL REPORT ___

   DIRECT INFLUENZA A ANTIGEN TEST (Final ___: 
      POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. 
         REPORTED BY PHONE TO ___ AT 1153  ___.
.
IMAGING:
CXR ___:
IMPRESSION: 
1. No acute chest pathology with stable pleural parenchymal 
scar. 
2. Flattening of the hemidiaphragms consistent with COPD. 

 
Brief Hospital Course:
A/P: ___ year old woman with recent onset of fevers, productive 
cough and costochondral vs. pleuritic pain who tested positive 
for influenza A.
.
# Fevers, malaise, cough: Pt seemed to have onset of symptoms 
consistent with viral infection.  She was admitted to the 
hospital and placed on droplet precautions because there was 
concern that she had the flu.  She was empirically started on 
Oseltamivir 75mg PO BID.  nasopharyngeal swab was positive for 
influenza A.  She was continued on a five day regiment of 
oseltamivir for her flu and will follow up with Dr. ___ in the 
outpatient setting.
.
# COPD exacerbation:  Pt tested positive for the flu, but seemed 
to also be having a COPD exacerbation with worsening dyspnea and 
sputum production.  She was started on prednisone 50mg PO Daily, 
Azithromycin and O2 via nasal cannula.  Her resting O2 sat was 
initially 85%, but at the time of discharge she was satting 96% 
on RA, but would desaturate to 84% after walking 75-100feet.  
She Was given a 5 day course of azithromycin, 5 days of 
prednisone at 50mg PO Daily and then a week long taper and 
discharged on home O2 while her symptoms improved.  The patient 
was breathing more comfortably and ambulating well at the time 
of discharge.  She will follow up with Dr. ___ as well as Dr. 
___ in the outpatient setting.
.
# ASTHMA: pt with wheezing in the ED and at PCP office, but not 
present on my exams, however, she had received duonebs prior to 
my exam.  Likely having asthma symptoms in setting of COPD 
exacerbations.  She was continued on her home regiment and also 
on standing nebulizers.  She was discharged with nebulizer 
treamtents as well as her home medications.  Respiratory status 
was described above.
.
HYPERTENSION: Pt slightly hypertensive in the ED, but will 
continue meds at current regiment and reassess in the morning.  
Her BP meds are actively being uptitrated in the outpatient 
setting.  She remained normotensive during her hospital stay on 
the floor.  We continued Diltiazem ER 360mg PO Q24H, HCTZ 12.5mg 
PO DAILY, IMDUR ER 60 mg PO DAILY.
.  
GERD: Currently asymptomatic.  We continued omeprazole 20mg PO 
Daily
. 
CAD: Pt was recently diagnosed with single vessel disease.  She 
is asymptomatic at this time, but we will continue to monitor 
her for symptoms during this admission. 
We continued aspirin 81mg PO DAILY
.
TOBACCO ABUSE: Pt had been smoking for many years, but said that 
she quit yesterday and has no need for a nicotine patch or gum 
at this time.  
.

 
Medications on Admission:
1. Lisinopril 5mg PO Daily
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap  

PO DAILY (Daily).  
3. cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY  
(Daily).  
5. metoprolol succinate 100 mg Tablet Sustained Release 24 hr  
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.  
6. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 
 
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable  

PO DAILY (Daily).  
8. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)  
Capsule, Sust. Release 24 hr PO DAILY (Daily).  
9. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) 
 
Capsule, Sust. Release 24 hr PO DAILY (Daily).  
10. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID  
W/MEALS (3 TIMES A DAY WITH MEALS).  
Disp:*540 Tablet(s)* Refills:*2*  
11. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.  

 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four 
(4) hours as needed for pain.  
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 
Two (2)  Inhalation every ___ hours.  
3. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
4. oseltamivir 75 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day) for 3 days.
Disp:*5 Capsule(s)* Refills:*0*
5. prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day 
for 7 days: Take 5 tabs for 2 days, then 4 tabs for 2 days, then 
2 tabs for 2 days, then 1 tab for 2 days.
Disp:*19 Tablet(s)* Refills:*0*
6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) 
Capsule, Extended Release PO DAILY (Daily).  
7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) 
Spray Nasal DAILY (Daily).  
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: 
One (1) Disk with Device Inhalation BID (2 times a day).  
9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
10. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr 
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).  
11. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: 
One (1) Cap Inhalation DAILY (Daily).  
14. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One 
(1) Tablet, Chewable PO DAILY (Daily).  
15. multivitamin     Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
16. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.  
17. Oxygen
Home Oxygen @ 2LPM Continuous via nasal cannula, conserving 
device for portability.  Pulse dose for portability.

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary Diagnosis:
Influenza
COPD exacerbation
.
Secondary Diagnosis:
ASTHMA   
HYPERTENSION   
HYPERLIPIDEMIA   
HEADACHE   
OSTEOARTHRITIS   
ATYPICAL CHEST PAIN   
TOBACCO ABUSE   
ABNORMAL CHEST XRAY   
COPD 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You are being discharged from ___.  It 
was a pleasure taking care of you.  You were admitted to the 
hospital for symptoms that were similar to a common cold as well 
as worsening respiratory status.  You tested positive for the 
flu and we also believe that you are having a COPD exacerbation. 
 You were started on high dose steroids, azithromycin, tamiflu 
and nebulizers.  You were also placed on oxygen.  You are now 
doing better, but may require O2 at home for some time as your 
infection resolves and your inflammation improves.
.
The Following medications were STARTED:
Prednisone 50mg 1 day, on ___ decrease to 40mg Daily for 2 
days, on ___ decrease to 20mg Daily for 2 days, on ___ 
take 10mg Daily for 2 days then stop  
Azithromycin 250mg by mouth Daily 1 day (last dose on ___
Tamiflu 75mg two times a day for 2.5 days (last dose on ___
You will also be sent on home O2
.
Please take your other medications as prescribed.
 
Followup Instructions:
___

{'fevers': ['Influenza with other respiratory manifestations'], 'non-productive cough': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis'], 'malaise': ['Influenza with other respiratory manifestations'], 'nasal congestion': ['Influenza with other respiratory manifestations'], 'intermittently productive cough': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis'], 'water diarrhea': ['Influenza with other respiratory manifestations'], 'vomiting without nausea': ['Influenza with other respiratory manifestations'], 'pain with coughing': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis'], 'wheezy': ['Chronic obstructive asthma with (acute) exacerbation'], 'hypoxic': ['Influenza with other respiratory manifestations', 'Chronic obstructive asthma with (acute) exacerbation', 'Obstructive chronic bronchitis with acute bronchitis']}