HOUSTON METHODIST · DISCHARGE SUMMARY
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PATIENT: Holloway, Margaret · DOB 1948-03-22 · MR 104-2293
ADMIT: 2026-05-06 · DISCHARGE: 2026-05-13 · LOS 7 days
ADMITTING DIAGNOSIS: Community-acquired pneumonia (J18.9), unspecified organism.
SECONDARY: Type 2 diabetes mellitus with hyperglycemia (E11.65). Hypertension, essential (I10). Stage 3 pressure ulcer, sacral (L89.153), present on admission.
HOSPITAL COURSE: Patient admitted from home with acute SOB and fever. CXR consistent with right lower lobe pneumonia. Treated with IV ceftriaxone 1g daily x 5d, transitioned to oral cefuroxime on day 6. Afebrile by day 3. Glycemic control with sliding scale insulin. Sacral wound assessed by wound care RN day 2 — Stage 3, 4cm x 3cm, no signs of infection.
PROCEDURES: None.
FUNCTIONAL STATUS · SECTION GG (admission baseline)
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GG0130A — Eating: 04 (Supervision)
GG0130B — Oral hygiene: 03 (Partial/moderate assistance)
GG0130C — Toileting hygiene: 03
GG0170A — Roll left and right: 03
GG0170B — Sit to lying: 03
GG0170C — Lying to sitting on side of bed: 03
GG0170D — Sit to stand: 02 (Substantial/maximal assistance)
GG0170E — Chair/bed-to-chair transfer: 02
GG0170F — Toilet transfer: 02
DISCHARGE MEDS (5): cefuroxime 500mg PO BID x 7d · metformin 1000mg PO BID · lisinopril 10mg PO daily · acetaminophen 650mg PO q6h PRN · insulin lispro sliding scale
RECENT LABS: Hgb 9.8 (L) · WBC 11.4 · Glucose 142 · K 3.4 (L) · Cr 0.9
DISPOSITION: SNF for skilled rehab + IV-to-PO antibiotic transition completion. Contact: KaraDayDemo Houston SNF, Bed 14B.