Hospital Progress note

Progress Note - 3 West, Room 12, Bed 3 ID: - 67, Female - Level of Care B (discussed) Reason for admission: - Acute exacerbation of chronic obstructive pulmonary disease (COPD) Past Medical History: - Hypertension, Type 2 Diabetes, Osteoarthritis Allergies - Penicillin Today: - Increased shortness of breath, productive cough OE: - Vital signs: BP 140/85, HR 88, Temp 37.2°C, RR 22, SpO2 92% on room air - Good General State, no distress, no work for breathing Heart: normal S1, normal S2 with no murmurs No LL Edema Lungs: Normal Vesicular breathing, No crackles, No wheezing Abdomen: Soft, no tenderness, no Rigidity, no Rebound, negative Mcburney sign Investigations: Labs: - CBC: WBC 12,000/mm³, Hb 13.5 g/dL, Platelets 250,000/mm³ Imaging: - Chest X-ray: Hyperinflation, no acute infiltrates Treatment Plan: 1. COPD exacerbation - Impression: COPD exacerbation - Treatment planned: Nebulised bronchodilators, oral corticosteroids - Relevant referrals: Pulmonology 2. Hypertension - Treatment planned: Continue current antihypertensive regimen 3. Diabetes management - Treatment planned: Adjust insulin dosage as per sliding scale 4. Discharge Planning & Other: - Prophylactic anti-coagulation: Lovenox - Foley catheter: No - GFR/Kidney function: GFR 65 mL/min/1.73m²