Hospital Progress Note

Progress Note

Hospital location: 4 North, Room 412, Bed 2

Identification

• 72 yo, Male
• Level of Care A

Reason for Admission

• Community-acquired pneumonia (CAP)

Past Medical History

• HTN, T2DM, dyslipidaemia, BPH

Allergies

• Penicillin (rash)

Today

• Improved SOB and productive cough. Tolerating PO diet well. Mobilising to bathroom with standby assist. Denies chest pain, fever, or chills.

OE

• BP 128/76 mmHg, HR 78 bpm, RR 16/min, Temp 36.8 °C, SpO2 95 % on RA
• Good general state, no distress, no increased work of breathing Heart: normal S1 and normal S2, without murmurs No lower-limb oedema Lungs: normal vesicular breath sounds, with no crackles or wheeze Abdomen: soft, non-tender, without rigidity or rebound; McBurney's sign negative

Investigations

Labs

• WBC 8.9 x 10^9/L (down from 14.2), Hb 132 g/L, Plt 245 x 10^9/L, Na 136 mmol/L, K 4.1 mmol/L, Cr 112 umol/L, eGFR 56 mL/min/1.73m2, CRP 24 mg/L

Imaging

• CXR (14/05/2024): Right lower lobe consolidation, no pleural effusion.
• ECG: Normal sinus rhythm at 76 bpm, no acute ischaemic changes.

Treatment Plan

1. Community-acquired pneumonia

• Community-acquired pneumonia
• Atypical pneumonia, viral respiratory tract infection
• Repeat CBC and CRP tomorrow morning
• Step down to doxycycline 100 mg PO BID x 5 days; wean O2 as tolerated (currently stable on RA)

2. Acute kidney injury (resolved)

• Pre-renal acute kidney injury
• Acute tubular necrosis
• Repeat basic metabolic panel tomorrow morning
• Discontinue IV fluids; encourage PO hydration; hold ramipril until Cr returns to baseline (95 umol/L)

3. Type 2 diabetes mellitus

• Type 2 diabetes mellitus
• Point-of-care blood glucose QID
• Resume home metformin 500 mg PO BID; continue insulin glargine (Lantus®) 10 units SC QHS
• Diabetes educator consult prior to discharge
• Continue ward mobilization and chest physiotherapy
• Ceftriaxone 2 g IV given at 08:00, doxycycline 100 mg PO given at 08:00, paracetamol (acetaminophen, Tylenol®) 1,000 mg PO given at 06:00
• Weaned off 2 L/min NP O2 to room air overnight; peripheral IV locked

4. Discharge Planning & Other:

• Expected date of discharge: 17/05/2024
• Prophylactic anti-coagulation : enoxaparin (Lovenox®) 40 mg SC daily
• Foley cathéter: No
• GFR/Kidney function: Cr 112 umol/L, eGFR 56 mL/min/1.73m2