Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Blood magnesium, Blood potassium normal, Blood urea normal, COVID-19, Cachexia
Clinical narrative: Discharge Summary    Date of Admission: 12/2/2023    Date of Discharge: 12/5/2023    Primary Care Physician: MD   Issues to be Addressed in Follow-up: Resolution of Symptoms   Reason for Hospital Admission (Admitting Diagnosis):  COVID-19 Disease   HPI on admission:  81-year-old male with a history of COPD (on home O2) and AIDS (CD4 count within normal limits), presented with fever, chills, and cough for the past several days, along with fatigue and weakness, Covid+ noted today, daughter with similar symptoms, Also reports shortness of breath for 3-4 days, His past medical history includes a recent hospitalization 1 month ago for suspected atypical pneumonia treated with ceftriaxone and azithromycin, where he showed heavy growth of candida in respiratory cultures but no PJP. His admission was complicated by transiently elevated LFTs, attributed to sepsis and not his stable ART regimen since 2016.      Hospital Course/Significant Findings: Patient was admitted and started on Remdesivir and Decadron. Patient symptoms improved and was back on his home 2L O2 by day of discharge and breathing comfortably at baseline. Discharge on course of Decadron.   Complications: None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? PULMONARY HTN   ? COPD STAGE 4 VERY SEVERE (FEV1 0-29%)       PFT 1/29/2019    ? CHRONIC HEPATITIS C   ? HYPERTENSIVE CKD, STAGE 3A (GFR 45-59)   ? EPILEPSY, UNSPECIFIED         ......................................................   ? SEIZURE, UNSPECIFIED   ? CHRONIC HYPOXEMIC RESPIRATORY FAILURE       Uses home oxygen 1.5 Liters from 4pm to 10am.   ? HYPERLIPIDEMIA   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA   ? EMPHYSEMA       Oxygen Dependent.   Last PFT 1/29/2019:    Spirometry: very severe obstruction is present (FEV1/FVC < 70%, FEV1 0-29%). An immediate response to inhaled bronchodilator is absent (defined as > or equal to 200mL increase AND > or equal to 12% increase in either FEV1, FVC, or both).  Lung Volumes:  Mild restriction is present (TLC < 80%).  Diffusion:  Testing not indicated based on NCAL regional diagnosis-based PFT testing algorithm.   Comparison to prior study:  Compared to prior study performed 1/5/2016 there has been a 0.25 L decrease in FVC and a 0.17 decrease in FEV1     ? HTN   ? AIDS (ACQUIRED IMMUNE DEFICIENCY SYNDROME)       AIDS dx as of 4/3/98.  Indication that lead to dx: CD4 <200 + pulm TB.  Reported to Health Dept on 5/5/98.      ? CACHEXIA     Resolved Hospital Problems No resolved problems to display.   Procedures: None   Consults:  None   Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code   Smoker: No.   Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).    Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Dec 08, 2023 To Be Determined Pt Discharge (P.T.)  HOME HEALTH AGENCY (HOME HEALTH AGENCY-VALU)   Jan 25, 2024 11:00 AM Video Visit (Msw) PALLIATIVE CARE    Feb 01, 2024 11:00 AM Video Visit (Msw) PALLIATIVE CARE      Physical Exam on Day of Discharge: BP 136/70  | Pulse 67  | Temp 97.6 °F (36.4 °C)  | Resp 20  | Ht 5' 8.5"  | Wt 51.5 kg (113 lb 8 oz)  | SpO2 96%  | BMI 17.01 kg/m²    Intake/Output Summary (Last 24 hours) at 12/5/2023 1151 Last data filed at 12/5/2023 0944  Gross over last 24 hours Intake 190 ml Output 1250 ml Net -1060 ml   General - A&Ox3. Resting comfortably in no acute distress Head - Normocephalic. Atraumatic Eyes - PERLA. EOMI Mouth - Oropharynx moist. No injection Neck - No lymphadenopathy. No JVD Lungs - Clear to auscultation. No wheezes, no crackles Heart - Regular rate and rhythm. No murmurs, no gallops Abdomen - Soft, nontender, nondistended, no guarding, no rebound Extremities - Good pulses bilaterally, no edema Musculoskeletal - Good strength bilaterally, no spinal tenderness Neuro - CN II-XII grossly intact, no sensory deficits Psych - Patient is of sound mind and proper affect   Selected Lab Results:  Recent Labs   12/05/23 0622 12/04/23 0803 12/03/23 0400 12/02/23 1414 WBC 6.6 5.7 6.5 10.5 HGB 10.9* 10.3* 10.0* 11.3* HCT 34.8* 32.8* 32.6* 36.2* PLT 181 171 175 200 MCV 101* 100 101* 102*      Recent Labs   12/05/23 0622 12/04/23 0803 12/03/23 0400 12/02/23 1414 NA 139 139 135 133* K 4.2 4.4 4.3 4.6 CO2 32 30 26 24 CL 102 105 102 98* BUN 18 17 18 16 CR 0.87 0.78 1.23 1.20 RBS 103 100 105 81 MG 1.8 1.9 1.8  --       Recent Labs   12/05/23 0622 12/04/23 0803 12/03/23 0100 AST 29 34 32 ALT 21 21 17 ALKP 81 89 100 TBILI 0.4 0.4 0.7      Lab Results Component Value Date   PT INR 1.0 08/01/2023   PT INR 1.2 03/23/2022   PT INR 1.0 02/06/2019   PT INR 1.0 01/23/2019   PT INR 1.0 12/27/2018   PT INR 1.0 02/14/2018      Recent Labs   12/02/23 1414 TROP 8   Time spent on discharge: > 35 minutes   Discussed with the patient. All questions fully answered.   12/5/2023 11:51 AM       Note Details  Author (D.O.) File Time 12/5/2023 11:53 AM Author Type PHYSICIAN (D.O.) Status Signed Last Editor Liu, (D.O.) Specialty Hospital Medicine Hospital Acct # Admit Date 12/2/2023  ED to Hosp-Admission (Discharged) on 12/2/2023  ED to Hosp-Admission (Discharged) on 12/2/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   CACHEXIA  SEIZURE, UNSPECIFIED  EPILEPSY, UNSPECIFIED  HYPERTENSIVE CKD, STAGE 3A (GFR 45-59)  CHRONIC HEPATITIS C  COPD STAGE 4 VERY SEVERE (FEV1 0-29%)  PULMONARY HTN  COVID-19 DISEASE  EMPHYSEMA  AIDS (ACQUIRED IMMUNE DEFICIENCY SYNDROME)  CAD (CORONARY ARTERY DISEASE) WO ANGINA  CHRONIC HYPOXEMIC RESPIRATORY FAILURE  HTN  HYPERLIPIDEMIA Care Timeline  12/03   Admitted from ED (Observation) 0435 12/05   Discharged 1636  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/5/2023) Medication List at Discharge   albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply is 1 canister  atorvastatin calcium 80 mg Oral DAILY, take 1 tablet daily by mouth for cholesterol control  clopidogrel bisulfate 75 mg Oral DAILY  dexamethasone 6 mg Oral DAILY  dolutegravir sodium 50 mg Oral DAILY  emtricitab/rilpiviri/tenof ala 200-25-25 mg 1 tablet Oral DAILY, with a meal  fluticasone propion/salmeterol 500-50 mcg/dose 1 Puff Inhalation 2 TIMES A DAY  furosemide 20 mg Take 1 tablet by mouth every Monday and Thursday.  gabapentin 200 mg Oral EVERY BEDTIME  guaifenesin 200 mg Oral EVERY 4 HOURS AS NEEDED  levetiracetam 500 mg Oral 2 TIMES A DAY  mirtazapine 30 mg Take 1 tablet by mouth at bedtime. For refills, please call refill recorder 72 hours in advance.  quetiapine fumarate 25 mg Oral EVERY BEDTIME  tiotropium bromide 2.5 mcg/actuation 2 Puffs Inhalation DAILY