Discharge Summary: 88-Year-Old Nursing Home Resident Hospitalized for Community-Acquired Pneumonia
PATIENT INFORMATION
Age: 88 years
Sex: [Male/Female]
Residence: [Name of Nursing Home]
Admission Date: [Date]
Discharge Date: [Date]
Length of Stay: [X] days
ADMITTING DIAGNOSIS
Community-acquired pneumonia
DISCHARGE DIAGNOSES
- Community-acquired pneumonia (resolved)
- Hypertension
- Heart failure with reduced ejection fraction
- Chronic kidney disease, stage 3
- Type 2 diabetes mellitus
- Mild cognitive impairment
HOSPITAL COURSE
This 88-year-old nursing home resident presented with acute respiratory symptoms including fever, increased cough, dyspnea, and hypoxemia (oxygen saturation <90% on room air). Chest radiography confirmed a new infiltrate consistent with pneumonia. 1 The patient was admitted for inpatient management given advanced age, multiple comorbidities (hypertension, heart failure with reduced ejection fraction, stage 3 chronic kidney disease, type 2 diabetes mellitus, mild cognitive impairment), and inability to maintain adequate oral intake—all factors that mandate hospitalization in elderly nursing home residents with pneumonia. 1
Initial severity assessment using validated criteria identified the patient as moderate-risk: respiratory rate >24 breaths/min and oxygen saturation <92% on room air were documented, meeting criteria for pulse oximetry monitoring and hospitalization. 1 Blood cultures were obtained prior to antibiotic initiation to enable pathogen-directed therapy. 2
Empiric antibiotic therapy was initiated immediately in the emergency department with ceftriaxone 1 gram IV daily plus azithromycin 500 mg daily, the guideline-recommended regimen for hospitalized non-ICU patients with comorbidities. 2 This combination provides coverage for typical bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) and atypical organisms (Mycoplasma, Chlamydophila, Legionella). 1, 2 Ceftriaxone required no dose adjustment despite stage 3 chronic kidney disease (estimated GFR approximately 30-59 mL/min/1.73m²), as it undergoes dual hepatic-renal elimination. 2
Supportive care included supplemental oxygen to maintain SpO₂ >92%, intravenous fluid resuscitation (monitored carefully given heart failure history), and continuation of home medications for chronic conditions with adjustments as needed. 1, 3 Vital signs (temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation) were monitored at least twice daily. 1, 4
Clinical improvement was documented by hospital day 3: the patient became afebrile (temperature <37.8°C for 48 hours), respiratory rate decreased to <24 breaths/min, oxygen saturation remained >90% on room air, hemodynamic stability was achieved (systolic blood pressure ≥90 mmHg, heart rate ≤100 bpm), and the patient was able to tolerate oral intake. 1, 2, 4 At this point, antibiotics were transitioned from IV to oral therapy with amoxicillin 1 gram orally three times daily to complete the treatment course. 2
Total antibiotic duration was 7 days (5 days minimum plus continuation until afebrile for 48-72 hours with no more than one sign of clinical instability). 1, 2 Blood cultures remained negative at 48 hours. No complications such as pleural effusion, empyema, or respiratory failure developed during hospitalization. 1, 3
DISCHARGE MEDICATIONS
- Amoxicillin 1 gram orally three times daily – Continue for [X] more days to complete 7-day total course 2
- [List home medications for hypertension, heart failure, diabetes, etc., with any adjustments made during hospitalization]
DISCHARGE CONDITION
Stable. Afebrile for >48 hours. Oxygen saturation >90% on room air. Tolerating oral intake and medications. Mental status at baseline. 4, 5
DISCHARGE INSTRUCTIONS
Activity: Resume baseline activity level as tolerated. Avoid overexertion during recovery period.
Diet: Regular diet as tolerated. Ensure adequate hydration (at least 1.5-2 liters of fluid daily unless restricted by heart failure management).
Medications: Complete the full course of amoxicillin as prescribed (total 7 days from hospital admission). 2 Continue all home medications for chronic conditions. Nursing home staff should monitor for medication adherence and adverse effects.
Monitoring: Nursing home staff should monitor temperature, respiratory rate, oxygen saturation, and mental status daily for the first week post-discharge. 4 Report any fever (temperature >37.8°C), increased respiratory distress, new confusion, or inability to maintain oral intake immediately to the covering physician. 1, 4
Warning signs requiring immediate medical evaluation:
- Fever recurrence (temperature >37.8°C)
- Worsening shortness of breath or increased work of breathing
- New or worsening confusion beyond baseline cognitive impairment
- Inability to tolerate oral medications or fluids
- Oxygen saturation <90% on room air
- Development of chest pain or hemoptysis 3, 4
FOLLOW-UP CARE
Clinical review at 48 hours: Nursing home physician or nurse practitioner should assess the patient within 48 hours of discharge to confirm continued clinical improvement, medication tolerance, and absence of complications. 1, 2
Follow-up at 6 weeks: Schedule clinical review approximately 6 weeks post-discharge with the nursing home physician or primary care provider. 1, 2, 4 A follow-up chest radiograph at 6 weeks is not routinely required if the patient demonstrates satisfactory clinical recovery; however, it should be obtained if symptoms persist, new physical signs develop, or there is concern for underlying malignancy (particularly relevant given advanced age). 1, 2, 4
Vaccination status: Ensure pneumococcal vaccination is up to date (20-valent pneumococcal conjugate vaccine alone OR 15-valent conjugate vaccine followed by 23-valent polysaccharide vaccine one year later for adults ≥65 years). 2 Administer annual influenza vaccine during fall/winter season. 2 These interventions reduce future pneumonia risk in this vulnerable population. 1
Smoking cessation: [If applicable] Continue smoking cessation counseling and support. 2
PROGNOSIS AND FUNCTIONAL EXPECTATIONS
Nursing home residents hospitalized for pneumonia face substantial risk of functional decline or death following discharge: approximately 90% experience severe disability (≥4 activities of daily living limitations) or death within months of hospitalization, even among those with minimal deficits prior to admission. 6 The nursing home care team should anticipate potential need for increased assistance with activities of daily living, rehabilitation services, and advance care planning discussions. 6 Close monitoring for functional decline, nutritional status, and mood changes is essential during the post-discharge recovery period. 7, 6
DISCHARGE DISPOSITION
Discharged to [Name of Nursing Home] in stable condition with completed antibiotic course and appropriate follow-up arrangements.
ATTENDING PHYSICIAN: [Name, MD]
DISCHARGE DATE: [Date]