Gastro-esophageal reflux disease without esophagitis Essential (primary) hypertension Bronchiectasis uncomplicated Elevated white blood cell count unspecified Dyspnea unspecified Weakness Adverse effect of glucocorticoids and synthetic analogues initial encounter Patient room in hospital as the place of occurrence of the external cause Personal history of nicotine dependence Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Sulfa (Sulfonamide Antibiotics) / Penicillins / fluconazole / 
Strawberry
 
Attending: ___.
 
Chief Complaint:
dyspnea
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
Ms. ___ is a ___ woman with asthma and
bronchiectasis who presents with dyspnea, cough, and weakness,
admitted for asthma exacerbation. 

Patient has been on Mass Health as her primary insurance. Over
the past ___ years, she has lost coverage at the beginning of the
year for various reasons and in the setting of being unable to
afford and obtain her maintenance medications, she has had
decomepnsation of her respiratory status. She lost her insurance
in ___, and between then and sometime in the last 3 weeks
when she was able to get it back, she has been unable to obtain
her long acting inhalers (initially Breo --> Symbicort). She has
had a number of ER visits to ___ due to respiratory
decompensation. In addition, she has been seen by Dr. ___
primary care physician and has been started on two courses of
steroids and antibiotics in the past month. Her most recent
course was started on ___ with a course of 18 days of
levofloxacin and prednisone. 

Patient reported progressive dyspnea and weakness over the past
few days. Denies fevers or chills. She reports cough productive
of clear sputum. Had musculoskeletal chest pain triggered by
cough. She denies sick contacts. She does have a young grandson
who is pre-___ in the home. She came to the ED for
evaluation. 

In the ED, patient's vitals were as follows: T98.3, HR 81, RR 
21,
BP 132/69, SpO2 100% on RA. CBC without leukocytosis. BMP wnl.
BNP slightly elevated at 148. Flu PCR negative. She was given
duoneb x 1, 80 mg methylpred, and 500 cc LR. She was admitted to
medicine for further work up and management. 
  

On arrival to the floor, patient reports interval improvement
with ED interventions. Less coughing. Able to complete sentences
now. 
 
Past Medical History:
Asthma: secondary to second-hand smoke
HTN
Hypercholesterolemia (? reported in Atrius but denied by 
patient)
GERD
Vertigo: had one episode one year ago, CT was negative, improved
with meclizine
Osteoarthritis of knee 
Dermatitis, eczematous 
Mitral valve insufficiency 

 
Social History:
___
Family History:
Mother & maternal grandmother with stroke. Father
and daughter with cancer. Grandmother with CAD/PVD.

 
Physical Exam:
Admission Physical Exam:
========================
VS - ___ 2207 Temp: 98.2 PO BP: 154/80 HR: 87 RR: 18 O2 
sat:
95% O2 delivery: RA 
GEN - NAD, speaking in hoarse voice but in complete sentences
HEENT - NCAT
NECK - supple, no LAD
CV - rrr, no r/m/g
RESP - diffuse expiratory wheezing with poor air movement
ABD - soft, nt/nd, +bs
EXT - no edema
SKIN - no rashes
NEURO - alert and oriented x 3

Discharge Physical Exam:
========================
VS: see Eflowsheets
GEN - NAD, speaking in complete sentences
HEENT - NCAT
NECK - supple, no LAD
CV - rrr, no r/m/g
RESP - diffuse expiratory wheezing with good air movement
ABD - soft, nt/nd, +bs
EXT - no edema
SKIN - no rashes
NEURO - alert and oriented x 3
 
Pertinent Results:
Admission Labs:
===============
___ 01:40PM BLOOD WBC-9.3 RBC-4.76 Hgb-13.1 Hct-40.9 MCV-86 
MCH-27.5 MCHC-32.0 RDW-15.6* RDWSD-48.2* Plt ___
___ 01:40PM BLOOD Neuts-79.9* Lymphs-15.2* Monos-3.3* 
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.45* AbsLymp-1.42 
AbsMono-0.31 AbsEos-0.02* AbsBaso-0.02
___ 01:40PM BLOOD Glucose-122* UreaN-25* Creat-0.9 Na-139 
K-4.5 Cl-101 HCO3-29 AnGap-9*
___ 05:26AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.2

Imaging:
========
CXR:
No acute cardiopulmonary process.

CT Chest:
Very mild bronchiectasis in the right lower lobe.
Residual secretions are noted inside the subsegmental bronchi in 
the left
lower lobe.

Discharge Labs:
===============
___ 06:15AM BLOOD WBC-16.0* RBC-4.46 Hgb-12.2 Hct-38.0 
MCV-85 MCH-27.4 MCHC-32.1 RDW-15.7* RDWSD-48.6* Plt ___
___ 06:15AM BLOOD Glucose-107* UreaN-25* Creat-0.8 Na-140 
K-4.7 Cl-98 HCO3-29 AnGap-13
___ 06:15AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.___ year old woman with a history of asthma and bronchiectasis 
who is here with exacerbation of respiratory issues.

# Dyspnea:
Presented with acute worsening of dyspnea. She has had multiple 
ED visits recently for the same issue, thought to be due to 
asthma exacerbations.
On admission, CXR was negative for acute abnormalities. BNP was 
normal.
She was noted to have a diffuse wheeze and was started on a 
steroid course (prednisone 60mg, as she had been taking 10mg 
daily at home as part of a taper).
She was seen by pulmonology, who felt that the diagnosis of 
asthma was questionable given the lack of obstruction on PFTs 
(see pulmonary note from ___ for full details).
They suspect that she may have vocal cord dysfunction. There may 
also be an element of GERD/aspiration, and post-nasal drip 
contributing to her symptoms, particularly since she reports 
that her cough is worse at night.
In addition, pulmonary felt that there was a significant 
component of anxiety contributing to her dyspnea, which patient 
acknowledged may be the case.
She also carries a diagnosis of bronchiectasis, but this was 
found to be very mild on CT chest.
She was discharged on a rapid prednisone taper. She was 
continued on home Zyrtec, Montelukast, and flonase as well as 
symbicort. Omeprazole was increased to BID.
___, ANCA, and IgE sent per pulmonary recommendations and were 
pending at time of discharge.
Pulmonary recommended outpatient ENT evaluation for vocal cord 
dysfunction, outpatient video swallowing study, and repeat 
outpatient PFTs. Patient reported that she would like to follow 
up with ___ pulmonary. An appointment was pending at time of 
discharge.

# Leukocytosis: developed leukocytosis to 16 with no fever or 
infectious signs. Likely steroid effect

# HTN : continued dyazide and amlodipine 

# GERD: continued omeprazole, which was increased to BID per 
pulmonary recommendations

> 30 minutes spent on discharge coordination and planning

Transitional Issues:
====================
- discharged on rapid prednisone taper
- omeprazole and flonase increased to BID
- ___, ANCA, and IgE pending at time of discharge
- pulmonology recommending outpatient ENT evaluation for vocal 
cord dysfunction, video swallow, and repeat PFTs
- patient reported that she wanted to follow up with ___ 
pulmonology. Appointment pending at time of discharge
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY 
2. Vitamin D 1000 UNIT PO DAILY 
3. Calcium Carbonate 500 mg PO DAILY 
4. Omeprazole 20 mg PO DAILY 
5. ZyrTEC (cetirizine) 10 mg Oral qd 
6. Montelukast 10 mg PO DAILY 
7. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze 
8. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral 
DAILY 
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 
10. amLODIPine 2.5 mg PO DAILY 
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 
inhalation BID 
12. LevoFLOXacin 750 mg PO Q24H 
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 

 
Discharge Medications:
1.  PredniSONE 60 mg PO DAILY 
Tapered dose - DOWN 
RX *prednisone 10 mg 6 tablet(s) by mouth once a day Disp #*32 
Tablet Refills:*0 
2.  Fluticasone Propionate NASAL 1 SPRY NU BID 
RX *fluticasone propionate 50 mcg/actuation 1 spry NAS twice a 
day Disp #*1 Bottle Refills:*0 
3.  Omeprazole 20 mg PO BID 
RX *omeprazole 20 mg 1 tablet(s) by mouth twice a day Disp #*60 
Tablet Refills:*0 
4.  Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze  
5.  amLODIPine 2.5 mg PO DAILY  
6.  Aspirin 81 mg PO DAILY  
7.  Calcium Carbonate 500 mg PO DAILY  
8.  Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral 
DAILY  
9.  Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze  
10.  Montelukast 10 mg PO DAILY  
11.  Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation 
inhalation BID  
12.  Vitamin D 1000 UNIT PO DAILY  
13.  ZyrTEC (cetirizine) 10 mg Oral qd  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:
Dyspnea
GERD
Asthma

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

 
Discharge Instructions:
Dear Ms. ___,

You came in because your breathing was becoming worse. You were 
seen by the pulmonary doctors, who felt that there were several 
different things contributing to your breathing problems. They 
recommended increasing your omeprazole to twice a day. This 
medication treats acid reflux and acid reflux can sometimes 
cause breathing issues.

You will also need to see an ear, nose and throat doctor as an 
outpatient and will need to have a video swallowing study.

We are sending you home on a prednisone taper:
___: take 6 tabs (60mg)
___: take 6 tabs (60mg)
___: take 6 tabs (60mg)
___: take 4 tabs (40mg)
___: take 4 tabs (40 mg)
___: take 2 tabs (20mg)
___: take 2 tabs (20mg)
___: take 1 tab (10mg)
___: take 1 tab (10mg)
___: stop prednisone

It was a pleasure taking care of you, and we are happy that 
you're feeling better!
 
Followup Instructions:
___

{'dyspnea': ['Dyspnea', 'unspecified'], 'cough': ['Gastro-esophageal reflux disease without esophagitis', 'Bronchiectasis', 'uncomplicated'], 'weakness': ['Essential (primary) hypertension', 'Elevated white blood cell count', 'unspecified'], 'musculoskeletal chest pain': ['Adverse effect of glucocorticoids and synthetic analogues', 'initial encounter'], 'sick contacts': ['Patient room in hospital as the place of occurrence of the external cause', 'Personal history of nicotine dependence'], 'productive cough of clear sputum': ['Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)']}