Discharge Summary
Patient Name: Russell Johnson
Medical Record Number: 123456789
Admission Date: 08/01/14
Discharge Date: 08/05/14
Attending Physician: Dr Gary Marshall
Dictated by: Dr Gary Marhsall
Primary Care Physician: Dr Dianna Miller
Referring Physician:
Consulting Physician(s): Dr Gary Marshall - hospitalist
Condition on Discharge: stable
Final Diagnosis: RLL pneumonia, COPD exacerbation, mild CHF, osteoarthritis
Procedures: none
History of Present Illness 72 year old thin white male presented to emergency on 8/1/14 with shortness
of breath, weakness and dehydration. Chest X-ray showed right lower lobe infiltrate, ABGs unremarkable.
Pulse ox on RA was 79%.
1) Pneumonia: treated with ceftriaxone and azithromycin iv. Switched to PO after 72 hours.
2) Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of
discharge
3) Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with
PT and regular meals.
Discharge Medications Zithromycin daily until gone, inhalers #of puffs,
Discharge Instructions: no activity restriction, regular diet, follow up in two to three weeks
with regular physician.