Location Inpatient Hospital Explained for Students (Easy Guide)

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Original Question

LOCATION: Inpatient, Hospital PATIENT: Ervin Gulman PRIMARY CARE PHYSICIAN: Ronald Green, MD ATTENDING PHYSICIAN: Gregory Dawson, MD The patient has a right-lung pneumonia, interstitial-type; COPD (chronic obstructive pulmonary disease) and chronic respiratory failure. Yesterday’s x-ray showed maybe some clearing. The sputum culture so far is not very helpful. The Gram stain does show evidence of gram-positive disease with moderate gram-positive cocci and moderate gram-positive cocci in clusters. He is taking Claforan and Zithromax, which should cover that. He seems to be responding and is a little more energetic. OBJECTIVE: He has been afebrile since he has been here. HEENT (head, ears, eyes, nose, throat): Benign. Neck: Supple without JVD (jugular vein distention). Chest: Symmetrical. Rales on the right. Very distant breath sounds. Left sounds pretty good. I do not hear any rales, anyway, but again, distant breath sounds. Heart: S1 (first heart sound) and S2 (second heart sound) are regular with a grade 1/6 murmur at the fourth interspace near the sternum that really does not radiate much. Abdomen: soft. Benign without hepatosplenomegaly. Extremities: No clubbing. No edema. The patient is a significant CO2 (carbon dioxide) retainer but does not really tolerate BiPAP much at all, and he tried that in the past. He seems to be quite claustrophobic and just cannot do it. I will put him back on his BuSpar, put him back on his Lasix today 40 mg (milligram) a day, and we will continue the rest of the drugs. We will start physical therapy with him a little bit to see if we cannot get him moving. His Solu-Medrol is every 6; go down to every 8 today. I would like to discharge him after a good 5 days of antibiotics, as I am sure the x-ray is better. SERVICE CODE(S): ________________________________________ ICD-10-CM DX CODE(S): ____________________________________

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