Underlying chronic obstructive pulmonary disease

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Reference no: EM133579974

Question

An 80-year old male was admitted with a 4 day history of increasing dyspnea, fever, and productive cough. Initial evaluation suggested right lower lobe pneumonia based on ED data. He was known to have underlying chronic obstructive pulmonary disease.

Physical Exam: Temperature 101.7, respiratory rate of 28, pulse 127, blood pressure 162.80. There were coarse crackles heard in the right base with poor air flow throughout.

Hospital Course: The patient was admitted for treatment of right lower lobe pneumonia. He was initially placed on Zinacef one gram q8 hours and Solumedrol 60 mg q6 hours. He was also provided with supplemental oxygen as required and supervised inhalation therapy. The Solumedrol was changed to Solumedrol on day 3 of admission. A right lower lob abnormality was seen via CT scan of the chest. On day 4 patient had a bronchoscopy which showed no distinct endobronchial lesion. Washings taken were negative for disease. Brushings showed only atypical cells. Perioperatively, the patient had some worsening of his CO2 retention, which was benefited by Bi-PAP for his sleep.

Discharge Information: Discharged to home with plans for continued antibiotics therapy and steroid taper, and arrangement for an outpatient fine-needle aspirate of the lung abnormality.

Discharge Medications: Atrovent, Albuterol, Ceftin, Prednisone.

The principal diagnosis for this inpatient admission per UHDDS definition is:

Reference no: EM133579974

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