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:

• COPD (diagnosed in 2070)

• Hypertension

• Type 2 Diabetes

• Coronary Artery Disease (CAD)

• Previous Hospitalization for COPD exacerbation (2085)

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:

• Continuous pulse oximetry

• Vital signs every 4 hours

• Daily chest X-ray

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:

1. Albuterol inhaler - 2 puffs every 4-6 hours as needed for shortness of breath.

2. Fluticasone/Salmeterol inhaler - 2 puffs twice daily.

3. Lisinopril - Continue as prescribed.

4. Metformin - Continue as prescribed.

5. Aspirin - Continue as prescribed.

Dietary Guidelines:

Maintain a balanced diet with an emphasis on hydration. Limit sodium intake.

Follow-Up Appointments:

1. Pulmonary follow-up within 1 week of discharge.

2. 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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