Age: 84.0
Sex: M
Vaccine: COVID19
Symptoms: Ejection fraction, Heart rate irregular, Hypertension, Hypervolaemia, Limb injury
Clinical narrative: Admit Date:  7/22/2022   Discharge Date:   7/25/2022   Discharge Diagnosis:  Principal Problem:   Acute respiratory failure with hypoxia Active Problems:   Open wound of left ankle   COVID-19   Chronic atrial fibrillation   HTN (hypertension)   Long term current use of anticoagulant therapy   Fluid overload     Hospital Course:  85 year old male was admitted for hypoxic respiratory failure. He also tested (+) for Covid-19 infection. He was treated with Remdesivir. Chronic wound on left leg was treated by wound nurse. He was initially on BiPAP but later was weaned off. He is not on O2 this morning. TTE showed LVEF >60%. He will be transferred back to home today. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 98.1 °F (36.7 °C) Heart Rate (Monitor): 81 Pulse: 80 BP: 140/78 Respirations: 18 SpO2: 94 % O2 Flow Rate (l/min): 0 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: irregular rate and rhythm Abdomen: soft, non-tender Skin: No rashes or lesions  Extremities: no edema Neuro: alert   Consults:  IP CONSULT TO SOCIAL WORK IP CONSULT TO WOUND CARE   Significant Diagnostic Studies:   TTE   Operations: none   Disposition:  long term care facility    Discharge Condition:  Fair    Discharge Medications:   Current Discharge Medication List   CONTINUE these medications which have NOT CHANGED   Details acetaminophen (TYLENOL) 500 mg tablet Take 500 mg by mouth Every 4 hours as needed for Pain.   petrolatum,white (BALMEX, PETROLATUM, EX) by Apply externally route As needed for Other (apply cream as needed).   cyanocobalamin, vitamin B-12, 1,000 mcg/mL Kit Administer 1,000 mcg/mL intravenously. USE 1000 MCG INTRAVENOUSLY ONE TIME A DAY EVERY 2 WEEKS ON Tuesday.   docusate sodium (COLACE) 100 mg capsule Take 100 mg by mouth Once Daily.   DOXAZOSIN MESYLATE, BULK, Take 4 mg by mouth Once Daily. TAKE ONE TABLE BY MOUTH EVERY DAY   Ferrous Fumarate (FERRETTS) 325 mg (106 mg iron) Tab Take 325 mg by mouth Once Daily.   HYDROcodone-acetaminophen (NORCO) 7.5-325 mg per tablet Take 1 Tablet by mouth Every 4 hours as needed for Pain.   vit E-glycerin-dimethicone (CETAPHIL MOISTURIZING) lotion by Topical route As needed.   levothyroxine (SYNTHROID) 25 mcg tablet Take 25 mcg by mouth Once Daily.   pva/gentian violet/methyl blue (HYDROFERA BLUE EX) by Apply externally route. CLEANSE WOUND ON LEFT MEDIAL ANKLE , PAT DRY, APPLY HYDROFERA, AQUACEL BORDER TO BE CHANGED EVERY OTHER DAY AND AS NEEDED   NIFEdipine (ADALAT CC) 30 mg CR tablet Take 30 mg by mouth Once Daily.   cholecalciferol, vitamin D3, (VITAMIN D3) 400 unit Tab tablet Take 50,000 Units by mouth Every two weeks.   warfarin (COUMADIN) 5 mg tablet Warfarin 5 mg daily except for 2.5 mg on Monday, Wednesday, Friday or as directed by Clinic Qty: 30 Tablet, Refills: 2   Associated Diagnoses: Chronic atrial fibrillation; Long term current use of anticoagulant therapy   carvediloL (COREG) 12.5 mg tablet Take 2 Tabs by mouth Twice a day. Qty: 120 Tab, Refills: 2   Associated Diagnoses: Uncontrolled hypertension   Benazepril 40 mg tablet Take 40 mg by mouth Daily. Indications: HYPERTENSION   PRAVASTATIN SODIUM (PRAVASTATIN PO) Take 80 mg by mouth At bedtime.   fenofibrate (TRIGLIDE) 160 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Atrial fibrillation   Aspirin 81 mg CpDR Take 1 Tab by mouth Daily.   Associated Diagnoses: Atrial fibrillation   PV W-O CAL/FERROUS FUMARATE/FA (M-VIT PO) Take 1 Tab by mouth Daily.   Associated Diagnoses: Atrial fibrillation     STOP taking these medications     doxepin (SINEQUAN) 10 mg capsule Comments:  Reason for Stopping:        spironolactone (ALDACTONE) 25 mg tablet Comments:  Reason for Stopping: