DISCHARGE SUMMARY

MOST RESPONSIBLE DIAGNOSIS Pneumonia MEDICAL PROFILE Hypertension, controlled with medication Type 2 Diabetes, A1C 7.2, stable Chronic Obstructive Pulmonary Disease (COPD), stable with inhalers COURSE IN HOSPITAL The patient, a 68-year-old male, was admitted on 1 November 2024 with shortness of breath and fever. Initial assessment revealed pneumonia, confirmed by chest X-ray. The patient was started on intravenous antibiotics and supplemental oxygen. Over the course of the hospital stay, the patient showed gradual improvement in respiratory function. A turning point was noted on day 4 when the patient was able to maintain oxygen saturation above 92% on room air. Discharge was delayed due to a brief episode of atrial fibrillation, which was managed with medication. COMPLICATIONS Atrial fibrillation DISCHARGE PLAN - Continue oral antibiotics for 7 days - Follow-up with primary care physician in 1 week - Pulmonary rehabilitation referral ISSUES PENDING AT DISCHARGE/TRANSFER - Awaiting results of sputum culture MEDICATIONS AT DISCHARGE - Candesartan 32 mg P.O. daily, continued at same dose - Metformin 500 mg P.O. BID, continued - Salbutamol inhaler, as needed, continued - Amoxicillin 500 mg P.O. TID for 7 days, started in hospital - Metoprolol 25 mg P.O. BID, started in hospital for atrial fibrillation