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Bronson, Genaro
MRN: 500101 Room: 226 DOB: 03/26/1957 Age: 68 Gender: Male Allergies: penicillin (rash 20 years ago)
 Admit Notes
 Clinical Notes
 Vitals
 Labs, Cultures, Imaging
 Clinical Calculators
 MAR
 Current Orders
 Home Med List
 Med Reconciliation
 Discharge Planning
Setting Adult Medicine Unit
Scenario Patient is admitted to hospital due to an acute COPD exacerbation.
Admission note taken on 12/14/25
CC "I can't catch my breath, and my cough is much worse."
HPI GB is a 68-year-old male with a significant history of GOLD 3 (Severe) COPD, hypertension, hyperlipidemia, and peripheral vascular disease, who presents with a 3-day history of worsening respiratory distress. GB states he was at his usual baseline state of health until 3 days ago, when he noticed a gradual increase in his shortness of breath. At baseline, he is ableto ambulate around his home and gets dyspneic after one flight of stairs. He uses home oxygen 2L via nasal cannula, primarily with exertion and at night. Over the past 72 hours, his dyspnea has progressed to the point where he is now short of breath walking 10 feet to the bathroom. He reports his chronic cough has become more frequent and "deeper." His sputum, which is usually scant and clear, has become "thick and yellow-green." He has been using his rescue Albuterol inhaler "every 2-3 hours" for the past 24 hours with minimal relief. He also notes new bilateral leg swelling and has had to sleep upright in his recliner for the past two nights due to orthopnea. He denies fevers or chills. He has not had any recent travel. He notes his grandson visited him one week ago and "had a cold." He denies any new or worsening chest pain or palpitations. He presented to the Emergency Department because his symptoms are "the worst they've been in a year" and his rescue inhaler is not working.
PMH
  • Chronic Obstructive Pulmonary Disease (COPD)
    • GOLD 3 Group D: Diagnosed 10 years ago.
    • Last exacerbation requiring hospitalization was 14 months ago. On 2L continuous home O2
  • Hypertension (HTN) x15 yrs
  • Hyperlipidemia (HLD) x10 yrs
  • Peripheral Vascular Disease (PVD) x2 yrs
Social
History
  • Tobacco: Current, active smoker. Smokes 1.5 packs per day. Has a 75-pack-year smoking history (1.5 PPD x 50 years). Has been counseled on cessation but is not ready to quit.
  • Alcohol: Drinks 2-3 beers, 1-2 times per week. Denies binge drinking.
  • Recreational Drugs: Denies all recreational drug use.
  • Living Situation: Lives in a single-story home with his wife, who is in good health.
  • Functional Status: At baseline, he is independent with all Activities of Daily Living (ADLs). Uses a cane to ambulate outdoors due to PVD.
  • Occupation: Retired plumber.
 Family
History
  • Father: Died at age 62 from a myocardial infarction. Had history of HTN and smoking.
  • Mother: Died at age 78 from a CVA (stroke). Had history of HTN and HLD.
  • Siblings: One brother, age 65, with HTN.
Vaccine
History
  • Influenza: received current season
  • COVID-19: received current season
  • Pneumococcal: received PPSV23 (Pneumovax) 10 years ago
  • RSV: received vaccine (Abrysvo) last year
  • Shingrix: completed 2-dose series 5 years ago
 Surgical
History
  • Left Femoral-Popliteal Artery Bypass Graft (2 years ago)
  • Cholecystectomy, laparoscopic (15 years ago)
  • Appendectomy (50 years ago)
Physical Exam Review of Systems
  • Constitutional: Denies fever, chills. Reports fatigue.
  • HEENT: Denies sore throat, sinus congestion, or headache.
  • Respiratory: As per HPI: +worsening dyspnea, +productive cough, +purulent sputum, +wheezing.
  • Cardiovascular: +Bilateral lower extremity edema. +2-pillow orthopnea. Denies chest pain or palpitations.
  • GI: Denies nausea, vomiting, diarrhea, or abdominal pain. Appetite is decreased.
  • GU: Denies dysuria or hematuria.
  • Musculoskeletal: Reports baseline claudication in right calf. Denies new joint pain or swelling.
  • Neurologic: Denies dizziness, syncope, or focal weakness.
  • Skin: Denies new rashes or lesions.
  • Psychiatric: Denies anxiety or depression, but feels "frustrated" by his breathing.

Vitals
  • Temp: 99.2°F (37.3°C) (oral)
  • BP: 162/94 mmHg (sitting, right arm)
  • Heart Rate: 114 bpm (tachycardic, regular)
  • Resp. Rate: 28 breaths/min (tachypneic and labored)
  • O2 Sat: 86% on Room Air. Improves to 92% on 2L Nasal Cannula.

Physical Examination
  • General: 68-year-old male in moderate respiratory distress. Sitting upright on the stretcher, leaning forward. Using accessory muscles (scalenes, intercostals) to breathe. Speaking in 3-4 word sentences.
  • HEENT: Normocephalic. Mucous membranes are tacky. Sclera anicteric. Jugular Venous Distension (JVD) noted to 8 cm at 30 degrees.
  • Lungs: Increased AP diameter (barrel chest). Diffuse, bilateral expiratory wheezing and coarse rhonchi heard throughout all lung fields. Decreased air entry at the bases. Prolonged expiratory phase.
  • Heart: Tachycardic, regular rhythm. S1 and S2 are distant but distinct. No murmurs, rubs, or S3/S4 gallops.
  • Abdomen: Soft, non-tender, non-distended. Bowel sounds are present and normoactive. No hepatosplenomegaly.
  • Extremities: 2+ pitting edema bilaterally from the feet to the mid-shins. Skin on lower legs is cool, shiny, and hairless, consistent with PVD. Dorsalis pedis and posterior tibial pulses are trace (1+) bilaterally. Calves are non-tender. Brachial and radial pulses 2+ bilaterally.
  • Neurologic: Alert and oriented to person, place, and time (A&Ox3). Moves all extremities spontaneously. No facial droop or gross motor deficits.
Clinical Laboratory Report
 
Test Name 12/16/25 12/15/25 12/14/25 Range
Sodium (Na+) 144 148 138 136-145 mEq/L
Potassium (K+) 4.2 4.1 4.1 3.5-5 mEq/L
Chloride (Cl-) 108 109 102 98-106 mEq/L
Bicarbonate (HCO3-) 26 26 34 23-28 mEq/L
Urea nitrogen (BUN) 20 20 22 8-20 mg/dL
Creatinine 1.2 1.2 1.3 0.5-1.3 mg/dL
Glucose 110 108 115 70-115 mg/dL
Hemoglobin A1c 7.1 5.3-7.5 %
Calcium,Total 8.9 9.1 9.1 8.6-10.2 mg/dL
Phosphate 4.1 4.2 4.2 3-4.5 mg/dL
Magnesium 1.8 1.8 1.9 1.6-2.6 mEq/L
Protein, total 7.7 7.7 7.8 5.5-9 g/dL
Albumin 4.6 4.6 4.7 3.5-5.5 g/dL
Aminotransferase,aspartate (AST) 11 10 10 10-40 units/L
Aminotransferase,alanine (ALT) 13 13 12 10-40 units/L
Lactic dehydrogenase (LDH) 93 91 90 80-225 units/L
Alkaline phosphatase 69 70 67 30-120 units/L
Bilirubin, Total 0.5 0.5 0.5 0.3-1 mg/dL
Leukocytes (WBC) 11.3 11.2 14.2 4.5-11 x103/mcL
Red blood cells (RBC), Male4.34.44.33.8-5.1 x108/mcL
Hemoglobin, Male1717.317.514-18 g/dL
Hematocrit, Male52535342-50 %
Mean corpuscular hemoglobin (MCH) 32 31 31 27-33 picogram
Mean corpuscular volume (MCV) 82 82 81 76-100 mcm3
Platelets 248 248 250 150-450 x103/mcL
International normalized ratio (INR) 0.9 0.9 0.9 0.8-1.2
Prothrombin time (PT) 9.6 9.9 9.8 9.5-11.3 sec
Partial thromboplastin time,activated (aPTT) 31 31 30 25-35 sec

 
 
Additional Labs:
Fasting Lipids(3 days ago)
TC (mg/dL)235
TG (mg/dL)210
HDL-C (mg/dL)32
LDL-C (mg/dL)161
Other Labs (3 days ago)
BNP (pg/mL) 650
Troponin-T (HS) (ng/L) 25
Procalcitonin (ng/mL) 0.6
Arterial Blood Gas (3 days ago)
pH 7.32
pCO2 (mmHg) 68
pO2 (mmHg) 62
Interpretation Acute-on-Chronic Hypercapnic Respiratory Failure
Cultures:
Sputum Culture & Gram Stain (Collected in ED)
Gram Stain 4+ PMNs (polymorphonuclear leukocytes), 2+ Gram-positive cocci in pairs and chains, 3+ Gram-negative coccobacilli.
Culture (Preliminary) Moderate growth of Haemophilus influenzae (Gram-negative coccobacilli) and light growth of Streptococcus pneumoniae (Gram-positive cocci). Final sensitivities pending.
Imaging Studies:
Lung Function Tests (3 days ago)
FEV1 1.1 L (38% predicted)
FVC 3.0 L (75% predicted)
FEV1/FVC Ratio 0.37 (Marked obstruction)
Post-Bronchodilator FEV1 1.2 L (41% predicted)
DLCO (Diffusing Capacity) 45% predicted
Staging GOLD 3 (Severe) based on FEV1. Group D based on symptom burden and hospitalization history
Chest X-Ray (3 days ago)
Lungs Severe hyperinflation with flattened diaphragms. Increased AP diameter.
Markings Coarse interstitial markings and peribronchial thickening. No focal consolidation or definite pneumothorax
Heart Cardiomegaly noted. Prominent pulmonary arteries.
Impression Chronic obstructive lung disease. No acute pneumonia. Findings suggestive of pulmonary hypertension and cor pulmonale.
EKG (12-Lead) (3 days ago)
Rhythm Sinus Tachycardia, rate 112 bpm.
Axis Right Axis Deviation.
Findings P-pulmonale (peaked P-waves in leads II, III, aVF). Right ventricular hypertrophy pattern (dominant R in V1, S in V6). No acute ST-T changes.
Vital Sign 12/16/25
07:27
23:51
17:35
 12/15/25
09:40
22:15
16:50
 12/14/25
09:21
Height (cm) 180 180 180
Weight (kg) 81.8 80 81.8
Body Temperature (°C) 37.2 36.5 36.5 37.9 37.3 37.3 37.3
Blood Pressure (mmHg) 160 / 92 161/90 158/92 161/90 160/95 163/95 162/94
Heart Rate (bpm) 98 100 95 98 115 117 114
Respiratory Rate (bpm) 20 20 19 20 28 27 28
Oxygen Saturation (%) 92 90 93 92 85 86 86
Current Orders
 
CONC
VOL
SOLN
RATE

USE
START DATE
STOP DATE
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USE
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USE
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USE
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USE
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USE
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CONC
VOL
SOLN
RATE

USE
START DATE
STOP DATE
NOTES

 

 

USE
START DATE
STOP DATE
NOTES

 

 

USE
START DATE
STOP DATE
NOTES

 

 

USE
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STOP DATE
NOTES

 

 

Medication
History
  • None

 
Home Medication List: verified by pharmacy on admit (12/14/25)
 
Patient Name: Bronson, Genaro
Date of Birth: 03/26/1957
Room#: 226		 Allergies:
 Immunization History:
Community Rx Info:
 
Rx Insurance: 		Social History:
Additional Notes:
DRUG
STRENGTH
DF
STRENGTH
ROUTE
FREQ
PRN?
LAST
DOSE
(date/time)
ADVERSE
EFFECTS
ADHERENCE
NOTES
MED REC
ACTION
MED REC
REASON
Action Key:
C = Continue, D = Discontinue*, H = Hold*, M = Modify*
*must provide reason

                    
Medication 12/16/25 12/15/25 12/14/25
Doxycycline  100 mg  IV  BID
Rate: 100 mL/hr		09:30
09:18
21:35
09:35
21:35
Sodium Chloride 0.9%  60 mL/hr  IV  continuous infusion7:37
7:37
7:26
Prednisone  20 mg  PO  BID09:24
09:22
21:27
09:27
21:37
Umeclidinium/Vilanterol  62.5 mcg/25 mcg (1 puff)  INH  BID09:12
09:29
21:14
09:24
21:51
Lisinopril  40 mg  PO  QD09:33
09:49
09:12
Simvastatin  40 mg  PO  QD09:55
09:17
09:31
Aspirin  81 mg  PO  QD09:44
09:38
09:33
Clopidogrel  75 mg  PO  QD09:11
09:42
09:48
Enoxaparin  40 mg  Subcut  QD08:12
08:12
08:25
Omeprazole  20 mg  PO  QD09:47
Nicotine Transdermal Patch  21 mg/24 hr  TOP  QD09:33
09:54
09:36
Albuterol sulfate  216 mcg (2 puffs)  INH  Q6H  PRN
PRN yes, SOB		09:58
14:50
19:16
Albuterol Sulfate  2.5 mg/3 mL  NEB  Q4H until SpO2 >92%07:56
11:40
13:13
17:20
21:37
Clinical Notes
 
                    
Medication Discharge Orders
 
Hospital Medications
Medication Instructions Comments Continue Modify Discontinue New Rx sent

 
Previous Home Medications
Medication Instructions Comments Continue Modify Discontinue New Rx sent

 
 
Discharge Planning - Medication List and Instructions
 
Patient Name:
Admission Date: Discharge Date: Service:
Principle Diagnosis on Admission:
Secondary Diagnosis:
Allergies:

 
Medications ADDED this visit:
(begin taking these)		 Medications CHANGED this visit:
(modify what you were taking)		 Medications STOPPED this visit:
(stop taking these)

 
Final Discharge Medication List
Medication/Route/Dosage/Frequency/Duration Comments Morning Afternoon Evening Bedtime
As Needed Medications

 
          
Medication Reconciliation - Finalized Medication List
 
Patient Name: Bronson, Genaro Date of Birth: 03/26/1957 Room: 226

 
Medication (name/strength) Dose Route Frequency Notes

 
          
Height 180 cm
Actual Body Weight (ABW) 81.8 kg
Ideal Body Weight (IBW) 75.3 kg
ABW % of IBW 109 %
Adjusted Body Weight (AjBW) 77.9 kg
Body Surface Area (BSA) 2.02 m2
Body Mass Index (BMI) 25.2 kg/m2

Creatinine Clearance (Cockcroft-Gault Equation):
68 mL/min

 
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