Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Acute kidney injury, Anxiety, Biliary dilatation, COVID-19
Clinical narrative: Date of Admission  01/17/2022   Date of Discharge  01/26/2022   Reason for Hospitalization   C/O SOB AND NV; DECREASED PO INTAKE. RECENT EXPOSURE TO COVID.  Hospital Course       Patient is a 72-year-old F with pmh of HTN, CVA, COPD, chronic pancreatitis, Hx Alzheimer's, Diabetes and hypothyroidism admitted for COVID+ with sob and abdominal pain. In ED labwork remarkable for leukopenia, hypokalemia and AKI on CKD. Troponin mildly elevated but down trended with EKG NSR and no evidence of ischemia. Chest xray showed R perihilar opacity and mild cardiomegaly. Abdominal pain resolved shortly after admission, to which workup revealed a RUQ US positive for intrahepatic and extrahepatic biliary ductal dilation, with CBD measuring 15mmg and no stones appreciated. MRCP ordered in follow-up and revealed cystic structure near head of pancreas likely duodenal diverticula; CBD dilation 2/2 mass effect likely w/o evidence of choledocholithiasis. No further workup as to abdominal pain was recommended as pain resolved. In regards to COVID-19 pneumonia, patient was treated with dexamethasone x10days. She was started on baricitinib, but this was discontinued after 3 doses due to worsening renal function. Kidney function acutely worsened during hospitalization, urnie lytes consistent with pre-renal disease and improved after initiation of IV fluids. Continues to downtrend with ongoing encouragement in oral intake. Hospital course complicated by acute episodes of anxiety/confusion requiring sitter room but improved with prn hydroxyzine, to which there was initially concern for worsening covid infection however oxygen requirements stable and inflammatory markers downtrended. Patient also with uncomplicated UTI  (E coli) that was treated with 5 day course of cefpodoxime. Physical therapy recommended discharge to withheld, however after lengthy discussion with patient and patient's son there were concerns patient would not get the care she needs if going to the Neighborhoods with her husband who was also recently discharged there. She is agreeable to home health services (pt, ot and nursing) and the son feels patient is safe to discharge home as he lives upstairs and is able to assist with whatever else home health does not provide. Patient this morning remains on room air, hemodynamically stable and is to be discharged home with home health, and recommended to continue isolating for COVID until 1/28. She is recommended to follow-up with PCP, within a week and Nephrology within a month. Medication changes as listed below.  Discharge Diagnoses      1. COVID-19    Ordered:   Home Health     2. AKI (acute kidney injury)      3. CKD (chronic kidney disease), stage III      4. Diabetes mellitus type 2 in obese      5. UTI (urinary tract infection)      Recommendations at discharge:  - Restart Atenolol for blood pressure control  - continue holding hctz-lisinopril until further follow-up with pcp given poor kidney function  - do not restart Wellbutrin if patient has this remaining at home as this counteracts with her Keppra (pt reported not taking although was listed on med rec chart)  - F/U with pcp within 7 days  Other Diagnoses   Ongoing  BMI 31.0-31.9,adult  Obesity  Historical  No qualifying data  Operations and Procedures   None  Consultants   None  Pending Labs  None  Discharge Disposition  Home, Home Health   Medications  New, Changed, or Refilled Medications  None    Medications to be Continued  Miscellaneous Medication Fiber Gummies daily, 0 Refill(s)  Instructions:Fiber Gummies daily  SITagliptin (Januvia 100 mg) 0 Refill(s) Comments: Renal Dose Adjustments: CrCl >50 mls/min: 100mg qday,  CrCl 30-50 mls/min: 50mg qday,  CrC   albuterol-ipratropium (Combivent 1 Puff, Inhalation, qid, PRN: Wheezing, 0 Refill(s)    amitriptyline (amitriptyline 50 m 50 mg, 1 Tablet(s), Oral, At Bedtime, 90 Tablet(s)    atenolol (atenolol 100 mg) 100 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)    atorvastatin (atorvastatin 80 mg) 0 Refill(s)    calcium-vitamin D (Calcium 600+D) 1 Tablet(s), Oral, bid, 0 Refill(s)    dicyclomine (dicyclomine 10 mg) 0 Refill(s)    ergocalciferol (ergocalciferol 1. 50,000 IntUnits, 1 capsule(s), Oral, qWeek, 8 capsule(s), 0 Refill(s)    levETIRAcetam (levETIRAcetam 500 1,000 mg, 2 Tablet(s), Oral, q12h, 120 Tablet(s), 0 Refill(s)    levothyroxine (levothyroxine 125 See Instructions, Tablet(s) mcg Oral Daily  Instructions:Tablet(s) mcg Oral Daily  omeprazole (omeprazole 40 mg oral 0 Refill(s)    pancrelipase (Creon 36,000 units 2 capsules tid w/ meals & 1 capsule w/ each snack, Oral, As Directed, 240 capsule(s), 0 Refill(s)    rivastigmine (rivastigmine 13.3 m 13.3 mg, Topical, Daily    ropinirole (Requip) 0.5 mg, Oral, At Bedtime, 0 Refill(s)      Discontinued Medications  buPROPion (Wellbutrin 75 mg) 75 mg, 1 Tablet(s), Oral, bid    gabapentin (gabapentin 600 mg) 0 Refill(s)    hydrochlorothiazide-lisinopril (h 0 Refill(s)    zolpidem (zolpidem 10 mg) 10 mg, 1 Tablet(s), Oral, At Bedtime       Physical Exam at Discharge  Vitals & Measurements  T: 36.3 °C  HR: 64  RR: 16  BP: 140/65  SpO2: 92%      General: NAD HEENT: Normocephalic, Atraumatic, EOM intact, sclera clear, mucous membranes moist Respiratory: diffuse wheeze bilateral lower lobe, unlabored, symmetric chest rise Cardiovascular: RRR, no murmurs, rubs or gallops, normal S1/S2 Abdomen: soft, nontender, nondistended MSK: no gross deformities, normal ROM in all 4 extremities Neuro: alert and oriented, CN intact grossly Psych: normal affect and mood, cooperative Skin: Warm, dry intact  Time Spent  > 30 minutes   Follow Up Appointments     Follow Up Appt External Clinic or Provider, Clinic Name: Withheld, Provider Name: Withheld, Within 7 Days, No tests   Follow Up Appt Medicine Nephrology, Clinic Name/Phone: Withheld, Provider Name: Withheld, Within 1 Month, No tests    Nursing/Other Orders   Home Health. 01/26/22 12:43:00 Home Health Start Date 01/27/22, Fax Results To Withheld, Accepting Provider Withheld, 01/26/22 12:43:00, Assess and Treat, Evaluate and Treat, Evaluate and Treat, COVID-19 | Chest pain | Hypoxia   Diabetic, Heart Healthy Diet (low fat,low sodium). Ordered on 01/18/22 2:40:00, Meal Start Time Breakfast 0700 to 0900   Intake and Output (Strict I&O). 01/20/22 14:13:00, Continuous Order   Aspiration Precautions. 01/18/22 2:40:00 q24h   Fall Precautions. 01/18/22 2:40:00, Order comment: Assess Fall Risk Score Qday; Orientation/clarity/mental status;patient stability during ambulation/transfer (ie., gait, balance, streng ); Effectiveness of safety interventions    Activity As Tolerated. 01/18/22 2:40:00, Continuous Order   Code Status. Code Status Description: Full Code     Addendum by Withheld on January 26, 2022 14:51:13 (Verified)    Attestation by Withheld on January 26, 2022 14:51 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions:    None   Addendum by Withheld on January 26, 2022 18:56:38  (Verified)    After speaking with pharmacy in regards to home medications - called and spoke with patient to hold Januvia and continue Keppra at 500mg once daily given continued renal dysfunction until further follow-up with her pcp. She reflected understanding and stated she was scheduling an appointment to be seen within the next few days.