Age: 65.0
Sex: M
Vaccine: COVID19-2
Symptoms: Polymerase chain reaction negative, Pulmonary fibrosis, Pulmonary mass, Spinal pain, Sputum culture
Clinical narrative: Chest pain, Abdominal pain- Rule out cardiac Name:Age:65Admit Date:01/25/23Provider:         MD Room #: Dictation Date: 01/27/23 document embedded image                                               Discharge Summary Discharge Plan Admission/Discharge Dx Primary DC Diagnosis: Chest pain  Condition Condition: Stable  Discharge Detail Disposition: Home, Self-Care  Med Rec & New Prescriptions: Continued   rosuvastatin 10 mg tablet    10 mg PO QDAY Qty: 90 3RF   albuterol sulfate 90 mcg/actuation HFA aerosol inhaler    1 puff inhalation Q4H PRN (Reason: shortness of breath or wheezing) Qty: 18 5RF   gabapentin 300 mg capsule    300 - 600 mg PO HS Qty: 180 1RF   hydralazine 25 mg tablet    25 mg PO BID Qty: 180 1RF   fluticasone propionate 50 mcg/actuation spray,suspension    See Rx Instructions  .ROUTE .COMPLEX Qty: 48 1RF    Rx Instructions:    SPRAY 1 SPRAY IN EACH NOSTRIL ONCE DAILY   ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL solution for nebulization    3 ml NEB Q4HPRN PRN (Reason: Shortness Of Breath) Qty: 180 2RF   loratadine 10 mg tablet    10 mg PO QDAY Qty: 90 1RF   metoprolol succinate 50 mg tablet extended release 24 hr    See Rx Instructions  .ROUTE .COMPLEX Qty: 90 1RF    Rx Instructions:    TAKE ONE TABLET BY MOUTH EVERY DAY   valsartan 40 mg tablet    40 mg PO QDAY Qty: 90 1RF    Rx Instructions:    ADDED BY CARDIOLOGY 2/2022   fluticasone propion-salmeterol [Advair Diskus] 250-50 mcg/dose blister with device    1 ea INH BID   tramadol 50 mg tablet    50 mg PO TID MDD 3 PRN (Reason: pain) Qty: 90 0RF    Rx Instructions:    PMP- Reference    Discharge Education Printouts:  Abdominal Pain (ED)  Diet:: Cardiac diet  Follow Up Care/Instructions Diet/Activity/Wound Care..: 1.  Follow-up with primary care provider 3 to 5 days 2.  Cardiac stress test to be coordinated by primary care provider as outpatient 3.  Cardiac diet 4.  Activity as tolerated 5.  Follow-up imaging regarding right lung nodule and coordinate your primary care provider  *Discharge Patient* Discharge Orders: Discharge Order  (Routine); Ordered 01/27/23    Ordered By:      Admission  Information Admit Info/Diagnoses/Course Admission Information: Patient, a 65 year old M, admitted on 01/25/23 06:44 for CHEST PAIN Family MD      Hospital Course:: Discharge diagnosis: 1.  Chest pain 2.  Lung nodule right lower lobe 4 mm 3.  Hyperlipidemia 4.  Chronic lumbar spine pain 5.  DJD 6.  GERD 7.  Obstructive sleep apnea 8.  Obesity 9.  Hypertension  Plan: Patient hospitalized following COVID-19 vaccine booster with symptoms of chest pain and likely representing a vaccination side effect.  Troponin telemetry unremarkable.  Echocardiogram results:1. By visual inspection there does appear to be cardiac chamber dilatation of mild to moderate severity.  Name: Age:65 Admit Date:01/25/23Provider:         MD Room #:  Dictation Date: 01/27/23 document embedded image                                               Discharge Summary Discharge Plan Admission/Discharge Dx Primary DC Diagnosis: Chest pain  Condition Condition: Stable  Discharge Detail Disposition: Home, Self-Care  Med Rec & New Prescriptions: Continued   rosuvastatin 10 mg tablet    10 mg PO QDAY Qty: 90 3RF   albuterol sulfate 90 mcg/actuation HFA aerosol inhaler    1 puff inhalation Q4H PRN (Reason: shortness of breath or wheezing) Qty: 18 5RF   gabapentin 300 mg capsule    300 - 600 mg PO HS Qty: 180 1RF   hydralazine 25 mg tablet    25 mg PO BID Qty: 180 1RF   fluticasone propionate 50 mcg/actuation spray,suspension    See Rx Instructions  .ROUTE .COMPLEX Qty: 48 1RF    Rx Instructions:    SPRAY 1 SPRAY IN EACH NOSTRIL ONCE DAILY   ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL solution for nebulization    3 ml NEB Q4HPRN PRN (Reason: Shortness Of Breath) Qty: 180 2RF   loratadine 10 mg tablet    10 mg PO QDAY Qty: 90 1RF   metoprolol succinate 50 mg tablet extended release 24 hr    See Rx Instructions  .ROUTE .COMPLEX Qty: 90 1RF    Rx Instructions:    TAKE ONE TABLET BY MOUTH EVERY DAY   valsartan 40 mg tablet    40 mg PO QDAY Qty: 90 1RF    Rx Instructions:    ADDED BY  CARDIOLOGY 2/2022   fluticasone propion-salmeterol [Advair Diskus] 250-50 mcg/dose blister with device    1 ea INH BID   tramadol 50 mg tablet    50 mg PO TID MDD 3 PRN (Reason: pain) Qty: 90 0RF    Rx Instructions:    PMP- Reference    Discharge Education Printouts:  Abdominal Pain (ED)  Diet:: Cardiac diet  Follow Up Care/Instructions Diet/Activity/Wound Care..: 1.  Follow-up with primary care provider 3 to 5 days 2.  Cardiac stress test to be coordinated by primary care provider as outpatient 3.  Cardiac diet 4.  Activity as tolerated 5.  Follow-up imaging regarding right lung nodule and coordinate your primary care provider  *Discharge Patient* Discharge Orders: Discharge Order  (Routine); Ordered 01/27/23    Ordered By:      Admission  Information Admit Info/Diagnoses/Course Admission Information: Patient,  a 65 year old M, admitted on 01/25/23 06:44 for CHEST PAIN Family MD      Hospital Course:: Discharge diagnosis: 1.  Chest pain 2.  Lung nodule right lower lobe 4 mm 3.  Hyperlipidemia 4.  Chronic lumbar spine pain 5.  DJD 6.  GERD 7.  Obstructive sleep apnea 8.  Obesity 9.  Hypertension  Plan: Patient hospitalized following COVID-19 vaccine booster with symptoms of chest pain and likely representing a vaccination side effect.  Troponin telemetry unremarkable.  Echocardiogram results:1. By visual inspection there does appear to be cardiac chamber dilatation of mild to moderate severity.  2. The valvular structures are all not well visualized, grossly normal for the patient's age. 3. LV systolic function is also not well visualized.  Overall wall motion appears to be generally preserved.  Cannot estimate an ejection fraction. 4. Right ventricular size and function is grossly normal. 5. No pericardial effusion is visible. 6. Color flow and Doppler analysis reveals trivial tricuspid insufficiency. IMPRESSION: Very technically difficult study with limited results as above. Recommend follow-up with primary care provider for further evaluation management and coordination of cardiac stress test and consideration referral to cardiology given the inconclusive results of the echocardiogram above.  Repeat CT verbal report as per Dr. 4 mm right lower lung not nodule and left base density consistent with fibrosis, no pulmonary embolism.  Patient will be discharged home in stable condition to follow-up with primary care provider for further evaluation management right lung nodule Date of service:: 01/27/23