Patient Admission Note
Prepared By: [YOUR NAME]
Patient Information
Name: Mr. Liam Carlson
Age: 58
Gender: Male
Date of Birth: January 15, 2050
Address: 456 Whispering Meadows, Unit 33, Serenity Cove, TX 12345
Contact Number: 222 555 7777
Emergency Contact: Mrs. Susan Carlson (Spouse), 222 555 7777
Insurance Information: VitalSign Insurance, Policy Number: 123456789
Reason for Admission
The patient was admitted due to the exacerbation of chronic obstructive pulmonary disease (COPD). Mr. Carlson presented with severe shortness of breath, increased cough, and decreased oxygen saturation, necessitating immediate medical attention and admission for further management.
Clinical Findings
Vitals:
Blood Pressure: 140/90 mmHg
Heart Rate: 98 bpm
Respiratory Rate: 24 breaths per minute
Temperature: 98.6°F
Oxygen Saturation: 88% on room air
Physical Examination:
Mr. Carlson appears fatigued with increased work of breathing. Auscultation reveals diffuse wheezing and decreased breath sounds in the lower lung fields.
Symptoms:
Shortness of Breath (SOB)
Increased Cough
Medical History
Past Medical History:
Allergies:
No known allergies.
Medication History:
Albuterol inhaler (as needed)
Fluticasone/Salmeterol inhaler (twice daily)
Lisinopril 10mg daily
Metformin 500mg twice daily
Aspirin 81mg daily
Social History:
Mr. Carlson is a retired school teacher, a non-smoker, and lives with his spouse. He reports minimal alcohol intake. He is independent in activities of daily living.
Family History:
No significant family history of respiratory diseases.
Diagnosis
Based on chest X-ray findings and arterial blood gas analysis, Mr. Carlson has been diagnosed with an acute exacerbation of COPD with respiratory failure.
Management Plan
Treatment:
Oxygen therapy to maintain oxygen saturation > 90%
Nebulized bronchodilators (albuterol and ipratropium)
Systemic corticosteroids (methylprednisolone)
Antibiotics (azithromycin) for possible bacterial infection
Monitoring:
Pain Management:
No acute pain was reported. Analgesics as needed.
Nutrition:
Maintain a regular diet. Encourage increased fluid intake.
Activity:
Bed rest with gradual ambulation as tolerated.
Health Education and Counselling
Medication Instructions:
Albuterol inhaler - 2 puffs every 4-6 hours as needed for shortness of breath.
Fluticasone/Salmeterol inhaler - 2 puffs twice daily.
Lisinopril - Continue as prescribed.
Metformin - Continue as prescribed.
Aspirin - Continue as prescribed.
Dietary Guidelines:
Maintain a balanced diet with an emphasis on hydration. Limit sodium intake.
Follow-Up Appointments:
Pulmonary follow-up within 1 week of discharge.
Cardiology follow-up in 2 weeks.
Discharge Instructions:
Continue prescribed medications.
Follow-up with primary care physician.
Watch for worsening symptoms (increased SOB, chest pain) and seek prompt medical attention.
Patient and Family Counselling:
Discussed the importance of medication adherence, early recognition of worsening symptoms, and the necessity of follow-up appointments. Answered questions and addressed concerns.
By signing below, I acknowledge that I have discussed the above information with the patient and/or their family.
Dr. Lily Hopkins
Date: January 11, 2085
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