7.56) Discharge Summary Admit Date 3/19/20xx Discharge Date

7.56) Discharge Summary 

Admit Date 3/19/20xx

Discharge Date 3/25/20xx

Admitting diagnoses: Acute exacerbation of asthma, chronic obstructive pulmonary disease with acute exacerbation, acute bronchitis, hormonal replacement therapy

 

Discharge Diagnoses: Acute exacerbation of asthma, chronic obstructive pulmonary disease with acute exacerbation, acute bronchitis, tobacco dependence, and hormonal replacement therapy.

 

Discharge Instructions: patient is to follow up in the office in one week.

Discharge Medications: Spiriva as directed daily. Pulmicort inhaler two puffs p.o. every 12 hours, Serevent Diskus one puff p.o every 12 hours, Augmentin 500 mg p.o. 3 times a day for six days, prednisone 35 mg to decrease by 5 mg every day until gone.

 

Brief History: The patient is a 57- year- old white female who presents with an approximate one- day history of increasing dyspnea to the point where any ambulation required increasing effort as she could not catch her breath. The patient also had mild complaints of sore throat, neck pain, and headache, She denied any fever, although a low-grade one was present on admission. The patient also admitted to a nonproductive cough.

The patient had an acute exacerbation of asthma and was admitted to observation. The patient is known to have moderate persistent asthma. However, this did not clear with IV steroids, nebulizer treatments, or supportive therapy, so she was admitted for inpatient treatment of acute exacerbation of asthma with possible bronchitis and respiratory distress. During her initial two-day stay, Z-Pak, Decadron, and albuterol and Atrovent treatments were continued because her respiratory did not significantly improve. The patient had increased anxiety secondary to her nebulized treatment and her medication was changed to Xopenex with some improvement.

Chest X-ray was checked on the second hospital day, and a two-dimensional echocardiogram was ordered in addition to a pulmonary consult. The patient’s Zithromax was changed to Augmentin to better cover Haemophilus influenzae as a possibility. Inhaled steroids were added as the bronchodilators were continued. The patient’s respiratory distress subsequently improved with less agitation with continued high-dose Xopenex. The two-dimensional echocardiogram was normal. The patient’s respiratory condition improved with less dyspnea with her lung exam overall cleared. The patient was discharged in stable condition.

 

History and physical: This is a 57-year-old female who presents with an approximate one-day history of increasing dyspnea to the point where any ambulation required increasing effort, and she could not catch her breath. The patient stated that approximately one month ago some cold medication was phoned in for her, which cleared up her congestion but did not feel she totally got well. She was admitted from the emergency department to observation, but her symptoms did not resolve so she is being admitted for inpatient treatment. Patient smokes approximately one pack of cigarettes a day and denies any alcohol use.

Physical Exam

General: The patient is alert and oriented, appearing in mild to moderate respiratory distress

Lungs : Showed decreased breath sounds throughout with no wheezing present.

Abdomen:Soft and nontender, with good bowel sounds present

Extremities: No cyanosis or edema

The patient is currently on 2 L of nasal cannula with O2 saturations at approximately 92 percent. Her chest x-ray is unremarkable.

Assessment and plan: Acute exacerbation of asthma/chronic obstructive pulmonary disease/acute bronchitis. The patient will continue with Zithromax given at 500 mg p.o.q. 24 hours. Continued on 10 mg of Decadron q. 8 hours, given albuterol as well as Atrovent treatments on daily basis.

Hormone replacement therapy on Premarin 0.625 mg/day

Consultant report

Reason for Consultation: Acute bronchitis

Impression: Acute Bronchitis either representing acute exacerbation of chronic bronchitis and/or asthma. Cigarette use greater than 40-pack-years.

Recommendations: Change Zithromax to Augmentin because she has had antibiotics in the past 90 days, and there is a high incidence of resistant H. influenzae and streptococcal pneumonia.

Handheld steroids

Prophylactic H2 blockers and low molecular with heparin

Check sputum for eosinophils

Cigarette cessation

Discussion: The patient has purulent bronchitis and wheezing on top of chronic daily shortness of breath and wheezing. This is compounded by at least 40-pack-years of smoking history. It is difficult to tell if this is just chronic obstructive pulmonary disease exacerbation due to infection or whether or not she has a large component of asthma.

Whatever the initial diagnosis is, she would benefit with albuterol and Atrovent, inhaled steroids, and antibiotics.

 

 

On the long-term basis, she will need PFTs and a long-acting bronchodilator, Spiriva of Advair depending on the way she responds on her pulmonary function test abnormalities. Advair is recommended if the FEV1 is less than 50 percent; Spiriva would be a better choice if this all-chronic obstructive pulmonary disease.

Emergency Department Report: Chief complaint: Shortness of Breath

History of present illness: The patient is a 57-year-old female complaining of shortness of breath since yesterday evening. She states that breathing difficulty became very severe to the point that she felt like she could not catch her breath. She could not walk across the room without becoming severely dyspneic. Also complaining of soreness in her neck bilaterally and a headache.

 

Impression/Management plan: Breathing difficulty with marked bronchospasm, possible fever with chills present, Rule out superimposed pneumonia. Symptoms consistent with exacerbation of asthma. Initial oxygen saturation on presentation to the emergency department 89 percent on room air.

 

Course in the Emergency Department: The patient received intravenous fluids, Decadron magnesium. The patient did develop a fever in the emergency department with temperature up to 100.7-degree F, for which she received Tylenol. The patient received multiple nebulizer treatments in the emergency department and has persistent expiratory wheezes with somewhat labored respirations. Chest x-ray read negative for acute changes by my reading. The patient received initial dose of Zithromax in the emergency department. Decision for further treatment was made with an admission to the observation unit.

Final Diagnosis: Asthma with acute exacerbation

What is the correct code assignment for the admission?

  1. J45.41, J44,1, F17.210, Z79.890
  2. J45.41, J44.1, 544.0, F17.210, Z79.890
  3. J45.41, J44.1, J44.0, J20.9, F17.210, Z79.890
  4. J45.41, J44.1, J44.0, J20.97.52  History and Physical Exam

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