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PATIENT PRESENTATION

Medical Respite Care Admission Note

Chief Complaint

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.

Past Medical History

Depression

Generalized anxiety disorder

HCV (untreated)

Polysubstance use disorder (opioid, benzodiazepine, cocaine, heroin, alcohol)

Surgical History

N/A

Family History

Father: estranged; history of alcohol abuse

Mother: deceased from suicide

Social History

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.

Immunization

Pneumococcal (1 of 1, PPSV23) 10 years ago

Hepatitis B vaccine (2 of 3, Risk 3-dose series) 6 months ago

Insurance

Medicaid

Allergies

Erythromycin (hives)

Penicillin (hives)

Current Medications

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 ...

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