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I need finding, assessment,resolution,mon = Chief Complaint "My chest hurts, I can't catch my breath, and this cough is getting worse." = HPI Justin Case is a 60-year-old man with a past medical history significant for MI who was admitted to the hospital 5 days ago to undergo a scheduled surgical procedure following a recent diagnosis of colorectal adenocarcinoma with metastatic lesions to the liver. The patient was taken to the OR on hospital day 2 and underwent an exploratory laparotomy, diverting ileostomy, and Hickman catheter placement in preparation for chemotherapy. Postoperatively, the patient was transferred to the progressive ICU for his recovery without complication. The patient had no new complaints until hospital day 5 when he complained of retrosternal crushing chest pain radiating to the left shoulder and left jaw, shortness of breath, and a worsening cough with sputum production. The patient was noted to be in respiratory distress with a RR of 43 breaths/min, HR 153bpm, BP 162/103mmHg, and O2 saturation of 87%. He was then transferred to the medical ICU and underwent endotracheal intubation due to worsening respiratory status. Cardiac markers were obtained, given the patient's symptoms and history of MI. Imaging and blood & sputum cultures were obtained after patient transfer. =PMH CAD, S/P MI 3 years ago for which he did not undergo any surgical intervention =SH Lives with his wife Smokes one ppd 40 years Denies alcohol or illicit drug use Meds Patient states that he did not take any medications at home. Hospital medications include (ICU medication list): Aspirin 325mgPO1 dose, then 81mg PO daily Enoxaparin 70mg subcutaneously every 12 hours Esomeprazole 40mg PO daily Fentanyl 25mcg /hour IV continuous infusion Lorazepam 2mg hour IV continuous infusion Metoprolol 25mg PO every 12 hours Nicotine patch 21mg per day applied daily AIl NKDA =ROS Patient is experiencing significant chest pain, shortness of breath, and a cough with sputum production. He denies nausea, vomiting, or difficulty urinating. He complains of mild abdominal pain near his ostomy and incision sites. - Physical Examination Gen WDWN Caucasian man, initially anxious, ill-appearing, and in moderate respiratory distress; now, S/P endotracheal intubation and in NAD VS BP 162/103 mm Hg, P 147 bpm, RR 42 breaths/min, T 38.5C; Wt 70kg,Ht56 Skin Warm; no rash; no skin breakdown HEENT PERRLA; moist mucous membranes Neck/Lymph Nodes Supple; no lymphadenopathy Lungs/Thorax Scattered rhonchi with expiratory wheezing; diffuse bilateral crackles; decreased breath sounds in bilateral bases; right U Hickman catheter intact without erythemaAbd Soft; mildly distended; hypoactive BS; large liver palpated in RUQ; ileostomy in RLQ is pink and functioning; surgical incision is C/D/I Genit/Rect Deferred MS/Ext 1+ pitting edema; 2+ pulses bilaterally; good peripheral perfusion Neuro Prior to intubation, A&O3; CN II-XII intact; patient is now intubated and sedated m Labs - Cardiac Mark.

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Day of Discharge Progress Note CC: I am breathing a little bit better. can I go home now? History of Present Illness: The patient, Linda Brown, is a 63-year-old female who was admitted to the hospital 4 days ago with the complaint of increased dyspnea, a terrible cough with some sputum production, and feeling weak and tired. Her symptoms began one day prior to admission after she went to a concert in a smoky bar. When she was unable to climb the stairs in her home while carrying her laundry basket without stopping every few steps to catch her breath, she had her daughter bring her to the hospital. In the emergency department, her O2 saturation was in the high 80s, and a CXR showed hyperinflation of bilateral lungs and a flattened diaphragm. A chest CT scan showed emphysema in both lungs with evidence of damage to the alveoli in the bilateral lung bases. She was started on oxygen via nasal cannula, ordered nebulizer treatments of a bronchodilator every 4 hours and admitted for a course of antibiotics and steroids. Since her admission, her breathing has improved, and her energy has increased. She is anxious for discharge to home as she states that she isnt sleeping well in the hospital, and the food is terrible. Past medical history: -Hypertension -Asthma as a child -Postmenopausal -Vaginal delivery x3 - Gallbladder removed in her 40s Social history: -Works full time as a manager at Target. -Divorced, lives alone. She has three adult children who live in the area. -Smokes 1 pack of cigarettes daily, began smoking when she was 24. -Reports social alcohol use-2-3 drinks per day on the weekends and 1-2 drinks during happy hour several times a week with her co-workers. -Reports occasional marijuana use. Medications: Lisinopril Physical Examination: Vital signs: Temperature: 98.2F. Heart Rate: 97 beats per minute. Respiratory Rate: 20 breaths per minute. Blood Pressure 126/74 mmHg. Oxygen saturation: 96% on 4 liters O2 via nasal cannula HEENT Head: No sinus tenderness, normocephalic, atraumatic. Ears: Tympanic membranes intact; no erythema Eyes: PERRLA, Conjunctiva without erythema. Nose: Mucous membranes intact, without congestion. Throat/mouth: Mucous membranes moist without exudate, teeth within normal limits. No cervical adenopathy. Respiratory: On 4 liters O2 per minute via nasal Scattered rhonchi in the bilateral lung bases. Occasional cough without any sputum production. Heart: Normal sinus rhythm, no murmurs Abdomen: Nontender to palpation, + bowel sounds Extremities: No lower extremity edema bilaterally. No evidence of clubbing in bilateral hands. Neurological: Awake, alert, oriented to time, place, and person. Skin: Without rashes or ecchymosis. Laboratory evaluation: Blood cultures negative Assessment: Patient has a new diagnosis of COPD with features of emphysema, admitted with a COPD exacerbation. Plan: COPD exacerbation, currently stable, and patient is ready for discharge to home -Ordered short-acting bronchodilator, ipratropium bromi.

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