tokens: 879492218 YC 53470378 3210349 6/26/2004 12:00:00 AM PNEUMONIA Signed DIS Admission Date : 06/26/2004 Report Status : Signed Discharge Date : 07/08/2004 ATTENDING : MALTA FYFEZEISLEITZ MD CHIEF COMPLAINT : Shortness of breath . HISTORY OF PRESENT ILLNESS : The patient is a 38-year-old gentleman , Spanish-speaking , from the Taheimpromong , with no significant past medical history , who presents with shortness of breath x 2 months as well as a dry cough x 1 month . The patient was in his usual state of health until two months prior to admission when he began to notice shortness of breath on climbing flights of stairs . He stated that this became worse over the last month until he was noted to be short of breath at rest . He also states that he has had a dry and nonproductive cough for one month . He denied any fevers , chills , or night sweats . No nausea , vomiting , or diarrhea . He did note some weight loss over the past several months , though the amount was unknown . He denied any contact with TB positive patients . He describes a negative PPD one year prior to admission when he was in prison for one week . He did travel to the Taheimpromong , last in 01/2004 for three weeks . He did note multiple female sexual partners , although described using condoms except with his wife . He denies any IV drug use , did describe cocaine use last two months ago . He did drink alcohol three drinks per day , no withdrawal symptoms . In emergency room , he was noted to be afebrile with stable vital signs , was treated with IV fluids , azithromycin , and cefuroxime . PAST MEDICAL HISTORY : None . MEDICATIONS : None . ALLERGIES : No known drug allergies . SOCIAL HISTORY : The patient lives currently with a friend , he is from the Taheimpromong and has lived here for 13 years , he does note multiple sexual partners , although he notes using condoms with everyone except his wife , he reportedly had a negative PPD during his prison stay one year ago for one week . He traveled to the Taheimpromong last in 01/2004 for one month . He does drink alcohol three drinks per day , denies any current tobacco use . FAMILY HISTORY : Sister with bone cancer . PHYSICAL EXAMINATION UPON ADMISSION : Temperature 97.4 , heart rate 100 , blood pressure 142/89 , and O2 saturation 94% on room air . General exam revealed a well-developed , well-nourished gentleman in no acute distress . HEENT exam revealed sclerae to be injected . Pupils equal , round , and reactive to light . No lymphadenopathy was noted in the neck , there was a question of right axillary lymphadenopathy . Chest exam reveals coarse rhonchi with some bibasilar crackles . Abdominal exam revealed soft , nontender , and nondistended abdomen . Heart exam was regular rate and rhythm , tachycardic , with a flat jugular venous pressure . His extremities were without cyanosis , clubbing , or edema . His skin was clear , without rashes . There is no hepatosplenomegaly noted on abdominal exam . Neuro exam was alert and oriented x 3 . LABORATORY DATA UPON ADMISSION : Sodium 139 , potassium 3.5 , chloride 103 , bicarbonate 25 , BUN 9 , creatinine 0.9 , and glucose 83 . White blood cell count 11.2 , hematocrit 43.2 , and platelets 447,000 . EKG upon admission : Sinus tachycardia at 100 . Chest x-ray upon admission : Diffuse interstitial process / consolidation . HOSPITAL COURSE BY SYSTEM : 1. Pulmonary / Infectious Disease : The patient &apos;s differential diagnosis included initially a question of an atypical pneumonia or PCP . His PPD has been negative one year prior to admission , PPD was rechecked during this admission and was negative . He was ruled out for tuberculosis with an induced sputum x 3 , which showed no AFB . Chest CT showed bibasilar diffuse infiltrates , PCP was negative . Thus initially he had been started on prednisone and Bactrim , this was discontinued . He was continued on azithromycin and cefuroxime until bronchoscopy results were known , negative . Thus they were discontinued . He initially had refused HIV testing , however , was finally consented , HIV was noted to be negative . Pulmonary consult was invited , initially the patient refused bronchoscopy , however , did agree to it during his hospital stay . The results were negative for Micro , most likely diagnosis as per review of pathology is organizing pneumonia with possible diagnosis of BOOP and chronic inhalational injury was a possibility . The patient required supplemental oxygen to keep his oxygen saturation greater than 93% . Ambulatory saturation was 82% on room air . He was treated with supportive medical therapy for his cough . He was to follow up with pulmonary as an outpatient . 2. Cardiovascular : Echocardiogram was checked to rule out CHF , showed LVH and trace TR , ejection fraction of 60% without any pulmonary hypertension . 3. Heme /ID : Hepatitis serologies were negative . 4. FEN : The patient was kept on a house diet . His electrolytes were repeated p.r.n. 5. Prophylaxis : Lovenox . 6. Code status : Full . 7. Disposition : The patient was discharged to home in satisfactory condition with home oxygen . Multiple conversations were had with the patient as well as an interpreter stating the importance of not smoking and keeping flames away from his oxygen tank . He was sent home with LDAMC services to help with his medications as well as oxygen education . He was told to call a doctor or come to the emergency room should he have any further troubles , breathing , chest pain , or fevers . He was to follow up with Dr. Malta at Firmert Hospital on 07/23/04 at 3:00 p.m. , as well as Dr. Shawn Leick at the Stonho Health Care pulmonary division as directed . DISCHARGE MEDICATIONS : 1. Prednisone 60 mg p.o. q.a.m. 2. Bactrim double strength one tablet p.o. q.d. for PCP prophylaxis during his steroid course . eScription document : 0-3054851 WEBCtug Tel CC : Mata Fyfezeisleitz MD Verla Dictated By : KOTEHARBE , THRYNE Attending : FYFEZEISLEITZ , MATA Dictation ID 5149122 D : 11/06/04 T : 11/07/04