Name: ………………………………………………….….

……..
DOB: ………………………………. Gender:
…………….
MRN: …………………………….. NOG:
…………………
Attending Admission Note Adm. Date: …………………… Bed:

DATE: Thursday, September 17, 2020 TIME: 3:36 PM

CHIEF COMPLAINT: dyspnea
HISTORY: 68 yo female pt, with the past medical history mentioned below, presenting for 3 days hx of dyspnea
on exertion and mild dyspnea on rest associated with productive cough whitish sputum. Patient denies any
fever, chills, chest pain. Pt has no GI or GU symptoms.
To note: pt received a 7 day hx of Avalox starting the 18 th of July / Pt has Pseudomonas colonization of the
Pseudomonas

PMH: severe asthma complicated with Churg-Strauss syndrome on methotrexate

Chronic sinusitis
Severe osteoporosis related to corticosteroid dependence
Recurrent admissions for asthma exacerbations
2 episodes of acute severe asthma needing intubations
Progression to chronic respiratory failure type II treated with BIPAP and oxygen therapy(LTOT) (2L NC)

PSH: hernia repair- c-section

Allergies: Penicillin (rash)

Medications: prednisone 30 mg OD- Spiriva 2.5mcg OD- Combivent OD- Geriatric OD- Ventolin- Flixinase PRN- Perioctin
4mg PRN- Flutiform 250mcg/10 BID- Calpero D3 OD- Cical OD- Med folic 5mg twice per week (tues/wed)- ulcesp OD-
Ebetrexat 5mg 1/week (3 tabs) ( on Sundays)

REVIEW OF SYSTEM: negative otherwise

TEMPERATURE: 37.1 RESPIRATION: PULSE: 110 BP: 113/53 HEIGHT: WEIGHT: 52kg

GENERAL APPEARANCE: no in acute distress

NEURO: Alert & oriented x 3, normal motor function, normal sensory function, no focal deficits noted.
HEENT/NECK: Norm cephalic, atraumatic
LUNGS/HEART: coarse bilateral crackles and wheezing/ Nl S1S2
ABDOMEN: Bowel sounds normal, Soft, no tenderness, no masses, no pulsatile masses
GENITO-URINARY: No CVA tenderness
Extremities: No LLE, + PP
DIAGNOSTC TESTS:
CBC
WBC 13.71
HGB 11.6
PLT 223

Na: 143
K: 5.6
Cl: 94
Co2: 38
Urea: 76
Cr: 1.1

CRP= 13.8
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 Name: ………………………………………………….….
HGT first reading 307 second reading 126 (no actrapid given) ……..
DOB: ………………………………. Gender:
EKG unchanged from before/ incomplete RBBB …………….
MRN: …………………………….. NOG:
ABGs: on 1.5 NC pH 7.37/ Pco2 77/ PO2 67/ bicarb 44/ Spo2 92% …………………
Adm. Date: …………………… Bed:
CT chest prelim results: increase in micronodules and tree in bud appearance in the lower lobe suggestive of
progression of disease/ very less likely possibility of superimposed infection

IMPRESSION and PLAN:

68 yo female pt with a hx of asthma/ churg strauss syndrome presenting for asthma exacerbation with possible
superimposed infectious process
1) Started on atrovent/ Ventolin and solumedrol 40 IV TID
2) Mero 1g Q8 to cover for possible infection
3) Continue home meds
4) BIPAP 2 hrs am 2 hrs Pm and overnight to keep Spo2 between 90-92%

RESIDENT NAME & SIGNATURE: Reem Dimachkie PGY1 DATE 9/17/2020 TIME:3:36 PM

ATTENDING NAME & SIGNATURE: DATE TIME

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MR F-10 Ed.7