Hospitalist Discharge

HISTORY OF PRESENTING ILLNESS Patient presented to the emergency department with a three-day history of worsening shortness of breath, cough productive of yellow sputum, and fever. The patient reported feeling generally unwell with associated fatigue and myalgias. PAST MEDICAL HISTORY Significant for hypertension, type 2 diabetes mellitus, and a history of smoking. The patient also reports a previous episode of pneumonia two years prior. MOST RESPONSIBLE DIAGNOSIS Community-acquired pneumonia. CONTRIBUTING OR SECONDARY DIAGNOSES Hypertension, type 2 diabetes mellitus. COURSE IN HOSPITAL Patient was admitted to the hospital and started on intravenous antibiotics (ceftriaxone and azithromycin). Chest X-ray revealed right lower lobe consolidation. Sputum cultures were obtained. Patient's oxygen saturation improved with supplemental oxygen. Blood glucose levels were monitored and managed with sliding scale insulin. Patient's fever subsided, and cough improved. Antibiotics were switched to oral amoxicillin-clavulanate on day 3. Repeat chest X-ray showed improvement. MEDICATIONS AT DISCHARGE * Amoxicillin-clavulanate 875/125 mg orally twice daily for 7 days. * Lisinopril 20 mg orally once daily. * Metformin 1000 mg orally twice daily. * Albuterol inhaler, 2 puffs every 4-6 hours as needed for shortness of breath. MEDICATION CHANGES DURING HOSPITAL STAY Intravenous antibiotics were changed to oral antibiotics due to clinical improvement and patient's ability to tolerate oral medications. DISCHARGE INSTRUCTIONS Patient was instructed to continue all medications as prescribed. Follow-up appointment with primary care physician in one week. Patient was advised to monitor for worsening symptoms, including increased shortness of breath, fever, or chest pain. Patient was educated on proper inhaler technique. Patient was also advised to stop smoking and was provided with resources for smoking cessation.