HIM FPX 4610 Assessment 5 Discharge Summary: The Cardiorespiratory System
Capella university
HIM-FPX 4610 Medical Terminology
Prof. Name
November, 2024
Discharge Summary
Patient Profile: Mr. John Doe, 67, male, with a history of hypertension and type 2 diabetes, was admitted on 15 October 2024 to manage community-acquired pneumonia (Liu et al., 2023). The patient was admitted with a high fever, productive cough, and shortness of breath. Antibiotics intravenous were initiated along with supplemental oxygenation and respiratory therapy, which resulted in gradual improvement of the condition of the patient. He was stable on discharge on 22 October 2024, with normal vital signs and improvement of his respiratory status. Discharge instructions: He was to continue all of his prescribed medications. This included amoxicillin 500 mg twice a day for 5 days, metformin 500 mg daily for managing his diabetes, monitoring for return of fever, increase in cough, or shortness of breath, and a follow-up appointment with his primary care provider on October 29, 2024. He was also instructed to go on a low-sodium diet and fluid intake as tolerated. He was taught a comprehensive care plan and was able to remember all of his discharge instructions.
Discharge Summary Template
| Number | Medical Term or Abbreviation | Drug | Reason Drug Is Used |
| 1 | HTN | Lisinopril | Used to manage high blood pressure (hypertension) |
| 2 | DM | Metformin | Used to control blood sugar levels in diabetes(Tejedor et al., 2020) |
| 3 | CHF | Furosemide | Helps reduce fluid buildup in congestive heart failure |
| 4 | GERD | Omeprazole | Treats gastroesophageal reflux disease |
| 5 | COPD | Albuterol | Relieves bronchospasm in chronic obstructive pulmonary disease(Maddah & Barzegari, 2023) |
| 6 | MI | Aspirin | Used to reduce the risk of heart attack |
| 7 | AFib | Warfarin | Prevents blood clots in patients with atrial fibrillation |
| 8 | RA | Methotrexate | Manages symptoms of rheumatoid arthritis |
| 9 | UTI | Ciprofloxacin | Treats urinary tract infections (Zeng et al., 2020) |
| 10 | HLD | Atorvastatin | Lowers cholesterol levels (hyperlipidemia) |
HIM FPX 4610 Assessment 5 Reference
Liu, B.-Y., Zhang, D., Fan, Z., Jin, J.-J., Li, C.-H., Guo, R.-N., Li, X.-J., & Huang, Y. (2023). Role of clinical features, pathogenic and etiological characteristics of community-acquired pneumonia with type 2 diabetes mellitus in early diagnosis. Endocrine Metabolic & Immune Disorders – Drug Targets, 24(8), 958–966. https://doi.org/10.2174/0118715303273741231117060753
Maddah, S. A., & Barzegari, A. (2023). The effect of albuterol spray on hypoxia and bronchospasm in patients with chronic obstructive pulmonary disease (COPD) under general anesthesia: a double-blind randomized clinical trial. Ethiopian Journal of Health Sciences, 33(3). https://doi.org/10.4314/ejhs.v33i3
