Discharge Summary

Most Responsible Diagnosis

Community-acquired pneumonia

Medical Profile

COPD, moderately severe on baseline home tiotropium, previously stable with 1 exacerbation in the past year.

T2DM, well controlled on oral hypoglycemics with a recent HbA1c of 6.8 %.

Essential hypertension, well controlled on baseline ramipril.

Osteoarthritis of the bilateral knees, stable and managed conservatively.

Course In Hospital

72-year-old male admitted on 14/05/2024 with a 4-day history of productive cough, fever, and worsening SOB. Initial vitals in the ED showed T 38.6 °C, HR 108 bpm, BP 138/82 mmHg, RR 26/min, and SpO2 86 % on room air. CXR demonstrated right lower lobe consolidation. Labs were notable for WBC 15.2 x 10^9/L and Cr 142 µmol/L (baseline 88 µmol/L). He was started on supplemental O2 at 3 L/min via nasal prongs, IV fluids, ceftriaxone, doxycycline, and a 5-day course of prednisone for concurrent COPD exacerbation.

By 16/05/2024, his fever resolved, WBC trended down to 10.1 x 10^9/L, and Cr normalized to 86 µmol/L following IV rehydration. Ceftriaxone was stepped down to oral amoxicillin-clavulanate. He was successfully weaned to room air on 17/05/2024. Discharge was briefly delayed by 24 hours due to deconditioning and unsteady gait; inpatient PT assessed the patient and cleared him for safe discharge home with a 4-wheeled walker on 18/05/2024.

Complications

• Acute kidney injury (pre-renal, resolved with IV fluids)
• Inpatient deconditioning requiring physical therapy assessment

Discharge Plan

• Return home with spouse and utilize newly prescribed 4-wheeled walker for ambulation.
• Complete antibiotic and steroid courses as prescribed until 21/05/2024.
• Follow up with primary care provider in 1 week for clinical reassessment.
• Repeat chest X-ray in 6 weeks to ensure resolution of right lower lobe consolidation.
• Return to the ED if experiencing recurrent fever, worsening shortness of breath, or chest pain.

Issues Pending At Discharge/Transfer

• Finalization of sputum culture sensitivities (preliminary negative at 48 hours).
• Outpatient requisition provided for 6-week follow-up chest X-ray.

Medications At Discharge

• Amoxicillin-clavulanate (Clavulin®) 875/125 mg PO BID, started in hospital to step down from IV ceftriaxone, and continued on discharge until 21/05/2024.
• Doxycycline 100 mg PO BID, started in hospital and continued on discharge until 21/05/2024.
• Prednisone 50 mg PO daily, started in hospital and continued on discharge for 1 final dose on 19/05/2024.
• Salbutamol (Ventolin®) 100 mcg INH 2 puffs Q4H PRN, increased frequency in hospital and continued PRN on discharge.
• Tiotropium (Spiriva®) 18 mcg INH daily, continued in hospital and continued unchanged on discharge.
• Ramipril (Altace®) 5 mg PO daily, held in hospital due to acute kidney injury, restarted upon renal recovery, and continued unchanged on discharge.
• Metformin (Glucophage®) 500 mg PO BID, held in hospital during acute illness, and restarted at baseline dose on discharge.