Medical Respite Care Admission Note
Cough, severe weakness, shortness of breath
History of Present Illness
SS is a 41-year-old male with a past medical history significant for polysubstance use and hepatitis C virus (HCV) who was admitted to our medical respite facility from a local hospital. SS was hospitalized for 3 days for management of right-sided pneumonia and polysubstance use. On admission to the medical respite, SS reports productive cough is mild with white/yellow phlegm. He denies fever, chills, and shortness of breath. He continues to have overall weakness, but it is improving. SS will remain in the medical respite for continued management of these issues.
Generalized anxiety disorder
Polysubstance use disorder (opioid, benzodiazepine, cocaine, heroin, alcohol)
Father: estranged; history of alcohol abuse
Mother: deceased from suicide
Smoking: current every-day smoker (0.25 packs/day).
Smokeless tobacco: denies.
Alcohol: ¼ gallon vodka/day.
Drugs: heroin (last use 1 year ago—sniffed), cocaine and methamphetamine (last used 1 month ago).
Overdose history: × 3 (2 in rapid succession when living in North Carolina, with most recent overdose ~10 months ago in Boston).
Current housing: homeless and stays between two shelters.
Family life: chaotic; father verbally abusive to him and his mother.
Abuse history: emotional, witness to domestic violence and verbal abuse.
Pneumococcal (1 of 1, PPSV23) 10 years ago
Hepatitis B vaccine (2 of 3, Risk 3-dose series) 6 months ago
Bisacodyl 10 mg suppository, 1 suppository rectally once daily as needed constipation
Bupropion XL 150 mg, 3 tablets by mouth once daily
Cefpodoxime 200 mg, 1 tablet by mouth twice daily × 2 days
Diazepam 10 mg, 1 tablet by mouth three times a day × 1 day, then 0.5 tablets three times a day × 1 day, then 0.5 tablets every 12 × 1 day, then 0.5 tablets by mouth once daily × 1 day
Docusate 100 mg, 1 capsule by mouth twice daily
Folic acid 1 mg, 1 tablet by mouth once daily