tokens: 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 &apos;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 &apos;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 &apos;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 &apos;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 &apos;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