Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Haematocrit decreased, Haemoglobin decreased, Hypertensive urgency, Hypopnoea, Insulin-requiring type 2 diabetes mellitus
Clinical narrative: Date of Admission:7/26/2022 11:34 AM Date of Discharge: 7/27/2022     Discharge or Transfer to:Home   Discharge Procedure Orders Diet Cardiac   Activity As Tolerated   Follow up with your PCP Order Comments:    Order Specific Question Answer Comments Follow up when? 1 week     Medications:   Medication List   CHANGE how you take these medications  pantoprazole 40 mg DR tablet Commonly known as: PROTONIX Take 1 Tab by mouth Twice a day. What changed: when to take this   zinc sulfate 220 (50) mg Commonly known as: ZINCATE Take 1 Capsule by mouth Once Daily for 30 days. What changed: Another medication with the same name was removed. Continue taking this medication, and follow the directions you see here.     CONTINUE taking these medications  albuterol 90 mcg/Actuation inhaler Commonly known as: VENTOLIN HFA Take 2 Puffs by inhalation Every 4 hours as needed.   amLODIPine 2.5 mg tablet Commonly known as: NORVASC Take 1 Tablet by mouth Once Daily for 30 days.   * ascorbic acid (vitamin C) 500 mg tablet Take 1 Tablet by mouth Once Daily for 30 days.   * Ascorbic Acid 1,000 mg Tab   aspirin 325 mg tablet Commonly known as: ASPIRIN   atorvastatin 40 mg tablet Commonly known as: LIPITOR   busPIRone 15 mg tablet Commonly known as: BUSPAR   Cane Devi 1 Units As directed.   carvediloL 6.25 mg tablet Commonly known as: COREG Take 1 Tablet by mouth Twice a day.   cetirizine 10 mg tablet Commonly known as: zyrTEC   * cholecalciferol (vitamin D3) 400 unit Tab tablet Commonly known as: VITAMIN D3 Take 1 Tablet by mouth Once Daily for 30 days.   * Cholecalciferol (Vitamin D3) 2,000 unit Cap   clopidogreL 75 mg tablet Commonly known as: PLAVIX Take 1 Tab by mouth Daily. thinner   escitalopram oxalate 10 mg tablet Commonly known as: LEXAPRO   fluticasone propionate 50 mcg/Actuation nasal spray Commonly known as: FLONASE Spray 1 Spray in nose Daily. (in each nostril)   furosemide 20 mg tablet Commonly known as: LASIX   levothyroxine 100 mcg tablet Commonly known as: SYNTHROID   mirabegron 50 mg Tb24 ER tab Commonly known as: MYRBETRIQ Take 1 Tablet by mouth At bedtime.   nirmatrelvir-ritonavir 300 mg (150 mg x 2)-100 mg tablet therapy pack Commonly known as: PAXLOVID Take two 150mg tablets of nirmatrelvir with one 100mg tablet of ritonavir, (three tablets taken together), by mouth twice daily for 5 days. May be taken with or without food.  Indications: COVID-19 (emergency use authorization)   ONE-A-DAY MEN'S 50+ ADVANTAGE PO   oxybutynin 5 mg ER tablet Commonly known as: DITROPAN XL Take 1 Tablet by mouth Once Daily.   tamsulosin 0.4 mg capsule Commonly known as: FLOMAX Take 1 Capsule by mouth At bedtime. New dosage      * This list has 4 medication(s) that are the same as other medications prescribed for you. Read the directions carefully, and ask your doctor or other care provider to review them with you.      STOP taking these medications  dexAMETHasone 2 mg tablet Commonly known as: DECADRON         Consults: None   Final Diagnosis: Principal Problem:   Hypertensive urgency Active Problems:   Type 2 diabetes mellitus, with long-term current use of insulin   COVID-19 virus infection     Procedures: Ct head   Signed: 7/27/2022 1:05 PM    Note Creation:7/29/2022  Encounter Date:7/29/2022        History            Chief Complaint    Patient presents with    ?   Cough    ?   Other            COVID POSITIVE          Patient is a 77 y.o. male with a hx of CAD, anxiety, CVA, DM, HTN, and TIA presents to the ED c/o gradually worsening cough. Patient tested positive for covid on 7/23. Patient denies chest pain, shortness of breath, or fever. Patient denies any other pertinent symptoms or concerns. Patient denies any other aggravating or alleviating factors. Pt denies any other pertinent PMHx.                   Past Medical History:    Diagnosis   Date    ?   AAA (abdominal aortic aneurysm)            4.7    ?   Abnormal nuclear stress test   09/2021    ?   Ambulates with cane        ?   Aneurysm   12/04/2021        Aorta    ?   Anxiety        ?   Arthritis        ?   CAD (coronary artery disease)        ?   Chronic kidney disease, stage 3        ?   Community acquired pneumonia        ?   CVA (cerebral vascular accident)   2020    ?   Depression        ?   Diabetes mellitus        ?   E.coli infection            ecoli infection to bladder    ?   Esophageal dysphagia        ?   Fall        ?   GERD (gastroesophageal reflux disease)        ?   Hernia        ?   Hyperlipidemia        ?   Hypertension        ?   Lung disease        ?   Obese        ?   Precordial pain   09/2021    ?   Pulmonary fibrosis   09/2021    ?   S/P coronary artery stent placement        ?   S/P coronary artery stent placement   09/2021    ?   Shortness of breath   09/2021    ?   Sleep apnea            wears cpap unsure of setting    ?   Splenic artery aneurysm            per wife    ?   Thyroid disease            hypothyroid    ?   TIA (transient ischemic attack)        ?   Urge incontinence        ?   Urinary retention        ?   UTI (urinary tract infection)        ?   Viral hepatitis            gilbert syndrome                Past Surgical History:    Procedure   Laterality   Date    ?   ARTERIOGRAM - RENAL       1/15/2019        Arteriogram - Renal    ?   DRUG-ELUTING STENT PLACEMENT   N/A   9/6/2011        CORONARY DES PLACEMENT     ?   HX APPENDECTOMY            ?   HX BLEPHAROPLASTY   Bilateral        ?   HX BROKEN/FX BONES                R wrist  leg fx 2019 no sx , clavicle fx 2020    ?   HX CARDIAC CATHETERIZATION                x3    ?   HX CHOLECYSTECTOMY            ?   HX COLONOSCOPY   N/A   5/14/2012        COLONOSCOPY /C POLYPECTOMY VIA FORCEP   ?   HX COLONOSCOPY   N/A   5/14/2012        COLONOSCOPY /C POLYPECTOMY VIA SNARE(HOT)     ?   HX EGJ   N/A   11/30/2013        EGD     ?   HX EGJ   N/A   9/21/2020        EGD /C BIOPSY   ?   HX EGJ   N/A   1/22/2021        EGD /C BIOPSY    ?   HX EGJ   N/A   1/22/2021        EGD /C TTS ESOPHAGEAL BALLOON DILATION     ?   HX HERNIA REPAIR                4 times    ?   IVUS   N/A   9/6/2011        INTRACORONARY ULTRASOUND   ?   LEFT HEART CATH   N/A   1/15/2019        Left heart cath     ?   LEFT HEART CATH   N/A   12/13/2012        LEFT HEART CATH     ?   LEFT HEART CATH   N/A   12/20/2011        LEFT HEART CATH     ?   LEFT HEART CATH   N/A   9/6/2011        LEFT HEART CATH    ?   LEFT HEART CATH   N/A   8/17/2020        Left heart cath     ?   LEFT HEART CATH   N/A   9/17/2021        Left heart cath     ?   ULTRASOUND GUIDANCE   N/A   1/15/2019        Ultrasound Guidance                 Family History    Problem   Relation   Age of Onset    ?   Hypertension   Mother        ?   Heart Disease   Mother        ?   Stroke   Mother        ?   Heart Disease   Father        ?   Cancer   Father        ?   Renal Disease   Father        ?   Hypertension   Father        ?   Diabetes   Sister               Social History            Tobacco Use    ?   Smoking status:   Never Smoker    ?   Smokeless tobacco:   Never Used    Vaping Use    ?   Vaping Use:   Never used    Substance Use Topics    ?   Alcohol use:   No    ?   Drug use:   No          Patient is not a tobacco user.     No LMP for male patient.           Allergies    Allergen   Reactions    ?   Nitroglycerin   Other (See Comments)            BP dropped. Severe headache                Current Outpatient Medications on File Prior to Encounter    Medication   Sig    ?   albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler   Take 2 Puffs by inhalation Every 4 hours as needed.    ?   ascorbic acid, vitamin C, 500 mg tablet   Take 1 Tablet by mouth Once Daily for 30 days.    ?   cholecalciferol, vitamin D3, (VITAMIN D3) 400 unit Tab tablet   Take 1 Tablet by mouth Once Daily for 30 days.    ?   zinc sulfate (ZINCATE) 220 (50) mg   Take 1 Capsule by mouth Once Daily for 30 days.    ?   amLODIPine (NORVASC) 2.5 mg tablet   Take 1 Tablet by mouth Once Daily for 30 days.    ?   mirabegron (MYRBETRIQ) 50 mg Tb24 ER tab   Take 1 Tablet by mouth At bedtime.    ?   atorvastatin (LIPITOR) 40 mg tablet   Take 40 mg by mouth At bedtime.    ?   oxybutynin (DITROPAN XL) 5 mg ER tablet   Take 1 Tablet by mouth Once Daily.    ?   carvediloL (COREG) 6.25 mg tablet   Take 1 Tablet by mouth Twice a day.    ?   furosemide (LASIX) 20 mg tablet   Take 20 mg by mouth Daily.    ?   tamsulosin (FLOMAX) 0.4 mg capsule   Take 1 Capsule by mouth At bedtime. New dosage    ?   fluticasone propionate (FLONASE) 50 mcg/Actuation nasal spray   Spray 1 Spray in nose Daily. (in each nostril)    ?   cetirizine (ZYRTEC) 10 mg tablet   Take 10 mg by mouth At bedtime.    ?   pantoprazole (PROTONIX) 40 mg DR tablet   Take 1 Tab by mouth Twice a day. (Patient taking differently: Take 40 mg by mouth Once Daily.)    ?   escitalopram oxalate (LEXAPRO) 10 mg tablet   Take 10 mg by mouth Daily.    ?   Cane Devi   1 Units As directed.    ?   Cholecalciferol, Vitamin D3, 2,000 unit Cap   Take 2,000 Units by mouth Daily.    ?   Ascorbic Acid 1,000 mg Tab   Take 1,000 mg by mouth Twice a day.    ?   busPIRone (BUSPAR) 15 mg tablet   Take 15 mg by mouth Twice a day.    ?   MV,MINERALS/FA/LYCOPENE/GINKGO (ONE-A-DAY MEN'S 50+ ADVANTAGE PO)   Take 1  TAB by mouth Daily.    ?   clopidogrel (PLAVIX) 75 mg tablet   Take 1 Tab by mouth Daily. thinner    ?   levothyroxine (SYNTHROID) 100 mcg tablet   Take 100 mcg by mouth Once Daily. replacement    ?   aspirin 325 mg tablet   Take 325 mg by mouth Once Daily. Blood thinner    ?   [EXPIRED] nirmatrelvir-ritonavir (PAXLOVID) 300 mg (150 mg x 2)-100 mg tablet therapy pack   Take two 150mg tablets of nirmatrelvir with one 100mg tablet of ritonavir, (three tablets taken together), by mouth twice daily for 5 days. May be taken with or without food.  Indications: COVID-19 (emergency use authorization)            Review of Systems       Review of Systems   Constitutional: Negative for fever.        + covid positive   Respiratory: Positive for cough. Negative for shortness of breath.    Cardiovascular: Negative for chest pain.   All other systems reviewed and are negative.         Physical Exam              ED Triage Vitals [07/29/22 1300]    BP   BP Manual or Automatic?   Patient Position   BP Location   Heart Rate (Monitor)    (!) 175/93   Automatic   Sitting   Right Arm   58         Pulse   Pulse Source   Respirations   Temp   Temp Source    --   Radial   14   98.5 °F (36.9 °C)   Oral         SpO2   SPO2 Location   O2 Delivery   O2 Device   O2 Flow Rate (l/min)    99 %   --   Room air   --   --         FIO2 (%)   Pain Intensity 1   Exacerbated By   Relieved By   Quality    --   --   --   --   --         Duration                    --                          Physical Exam  Vitals and nursing note reviewed.  Constitutional:       General: He is not in acute distress.    Appearance: Normal appearance. He is not toxic-appearing.  HENT:      Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:      Extraocular Movements: Extraocular movements intact.  Cardiovascular:      Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:      Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.   Musculoskeletal:         General: No deformity.     Cervical back: Neck supple.   Skin:     General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:      General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.             MDM       Treatment:  Procedures     Medications - No data to display           Results for orders placed or performed during the hospital encounter of 07/29/22    Ferritin    Result   Value   Ref Range        FERRITIN   58.1   23.9 - 336.2 ng/mL    C-Reactive Protein    Result   Value   Ref Range        CRP QUANTITATIVE   <1.0   0.0 - 1.0 mg/dL    Sed Rate    Result   Value   Ref Range        SED RATE   12   0 - 15 mm/h    Lactate Dehydrogenase    Result   Value   Ref Range        LDH   174   91 - 180 [iU]/L    Troponin I    Result   Value   Ref Range        TROPONIN I   <0.03   0.00 - 0.02 ng/mL    PT INR    Result   Value   Ref Range        PROTIME   12.7   10.1 - 13.8 s        INR   1.1   0.9 - 1.1    Fibrinogen, Quantitative    Result   Value   Ref Range        FIBRINOGEN LEVEL   205 (L)   255 - 507 mg/dL    Procalcitonin, QN, S    Result   Value   Ref Range        PROCALCITONIN, QN, S   0.06   ng/mL    D-Dimer, QT    Result   Value   Ref Range        D-DIMER   223   151 - 318 ng/mL    CBC    Result   Value   Ref Range        WBC   7.8   4.5 - 11.0 10*3/uL        RBC   4.19 (L)   4.50 - 5.90 10*6/uL        HGB   13.7   13.5 - 17.5 g/dL        HCT   39.5   37.0 - 53.0 %        MCV   94.4   80.0 - 100.0 fL        MCHC   34.7   32.0 - 36.0 g/dL        MCH   32.8   26.0 - 34.0 pg        RDW   14.1   10.7 - 18.7 %        MPV   8.3   6.5 - 10.0 fL        Platelet Cnt   115 (L)   150 - 450 10*3/uL        Differential Type   Auto            Neutrophils   54.8   35.0 - 66.0 %        Lymphocytes   33.4   24.0 - 44.0 %        Monocytes   11.4   2.1 - 13.3 %        Eosinophils   0.1 (L)   0.3 - 5.0 %        Basophils   0.3   0.0 - 1.0 %        Neutrophils Abs   4.3   1.5 - 8.5 10*3/uL        Lymphocytes Abs   2.6   1.1 - 5.0 10*3/uL        Monocytes Abs   0.9   0.0 - 1.4 10*3/uL        Eosinophils Abs   0.0   0.0 - 0.5 10*3/uL        Basophils Abs   0.0   0.0 - 0.1 10*3/uL    Comprehensive Metabolic Panel    Result   Value   Ref Range        SODIUM   133 (L)   135 - 145 mmol/L        POTASSIUM   4.0   3.6 - 5.0 mmol/L        CHLORIDE   101   101 - 111 mmol/L        CO2   28   21 - 31 mmol/L        ANION GAP   4            GLUCOSE   191 (H)   70 - 110 mg/dL        CREATININE   1.1   0.6 - 1.2 mg/dL        BUN   28   2 - 32 mg/dL        CALCIUM   8.4 (L)   8.5 - 10.5 mg/dL        PROTEIN TOTAL   6.1   6.1 - 7.8 g/dL        Albumin   3.4   3.2 - 5.0 g/dL        T BILIRUBIN   0.7   0.2 - 1.0 mg/dL        ALP   67   42 - 121 [iU]/L        AST   29   10 - 42 [iU]/L        ALT (SGPT)   38   10 - 60 [iU]/L        OSMOLALITY   277   266 - 309        A/G Ratio   1.3            B/C   25 (H)   10 - 20        ESTIMATED GFR   65   mL/min              Results                            XR Portable Chest (Final result)    Result time 07/29/22 12:43:31                     Final result                                         Narrative:                                                                              Radiology     PATIENT NAME:                       MR#:    PROCEDURE DATE:  07/29/2022                       ACCOUNT#:    ACCESSION #:  ROOM#:    ORDERING PHYS:       Single view chest     History:  Suspected corona virus, no additional clinical history provided.     Impression:  Spans 07/26/2022     Findings:  Lung inspiration is shallow with cardiac enlargement and chronic  bibasilar scarring.  No segmental consolidation or additional acute finding.     Impression:  Cardiomegaly, otherwise chronic changes.                    THIS IS AN ELECTRONICALLY VERIFIED REPORT              7/29/2022 12:40 PM:               sem  DD:  07/29/2022  TD:  07/29/2022  JOB #:                                              Radiology  Page 1    of   1                                                          COPY                                               Plan:     ED RECHECK: Discharge: The pt is awake, alert and well appearing at time of reevaluation. I spoke with the patient about his ED work up, diagnosis and any further treatment. I discussed the importance of following up with his. PCP. I instructed him to return to the Emergency Room for new or worsening symptoms. All of the pt's questions were answered. The patient verbalized understanding. The patient is stable at time of discharge.     MDM     Progress Note:                    ED Prescriptions            Medication    Sig    Dispense    Start Date    End Date    Auth. Provider         benzonatate (TESSALON PERLES) 100 mg capsule   Take 1 Capsule by mouth Three times a day.   15 Capsule   7/29/2022                        Final diagnoses:    COVID-19    Cough                 ED Disposition                  ED Disposition    Discharge After Treatment        Condition    Stable        Comment    --                              Follow-up Information                 Schedule an appointment as soon as possible for a visit    Specialty: Family Medicine  Contact information:                              Emergency Department.     Specialty: Emergency Medicine  Why: If symptoms worsen  Contact information:   Additional information:                                            Discharge Instructions           QUARANTINE.     Recommend Vitamin C, Vitamin D, and Zinc.  Recommend Tylenol for fever control.     Monitor oxygen saturation with pulse oximetry at home. Come to the ER immediately if O2 < 90%.  Follow up with PCP via TeleHealth.  Return to the ER if symptoms worsen.            Discharge References/Attachments     COVID-19 (Coronavirus Disease 2019) (AfterCare(R) Instructions(ER/ED))                  Other Notes All notes        ED Notes         ED Notes          ED Notes       Additional Orders and Documentation        Results   Imaging    Microbiology          Meds            Orders            Flowsheets      Encounter Info:      History,       Allergies,       Detailed Report         Communications        Summary of Care Document  Sent 7/29/2022      Media  From this encounter    Scan on 8/18/2022    Electronic signature on 7/29/2022 1208 - E-signed    Electronic signature on 7/29/2022 1202 - E-signed         Clinical Impressions        COVID-19       Cough      Disposition        Discharge After Treatment  Condition: Stable             ED After Visit Summary (Printed 7/29/2022)             Follow-Ups          ?Schedule an appointment     ?Follow up with Emergency Department (Emergency Medicine); If symptoms worsen        Medication Changes        benzonatate 100 mg Oral THREE TIMES A DAY      Medication List at Discharge       Care Timeline   1127    Arrived  1220    Ferritin     Lactate Dehydrogenase     C-Reactive Protein     CBC      Fibrinogen, Quantitative      PT INR     Troponin I     Sed Rate     Procalcitonin, QN, S     D-Dimer, QT     Comprehensive Metabolic Panel   1239    XR Portable Chest  1305    SARS-CoV-2, QL, PCR (Rapid)   1459    Discharged