Age: 91.0
Sex: M
Vaccine: COVID19
Symptoms: AST/ALT ratio abnormal, Acute respiratory failure, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy
Clinical narrative: Date of Service Oct-24-2022 1038  Date of Admission Admit Date: Oct-20-2022  Date of Discharge Date of discharge Oct-24-2022  Allergies Codeine - Not Specified  Chief Complaint general weakness  Procedure(s) Performed None  Lab Results Oct-24-2022 0430 Serology PROCALC  0.48 Oct-24-2022 0430 Hematology WBC  6.2RBC  3.26HGB  9.2HCT  28.5MCV  87.4MCH  28.2MCHC  32.3RDW  14.9RDWSD  47.9PLT  247MPV  9.4AUTONEU%  65.3AUTOLYM%  18.6AUTOMON%  12.1AUTOEOS%  3.4AUTOBAS%  0.3AUTONEU#  4.0AUTOLYM#  1.2AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.02IG%  0.3 Oct-24-2022 0430 Chemistry GLUCOSE  101BUN  12CREAT  1.3MDRD GFR  52NA  138K  3.6CL  107CALCIUM  8.0CO2  23.3OSMO  275.6ANION GP  11.3BUN/CRE  9.2CRP  3.30MAGNESIU  1.7 Oct-21-2022 0830 Microbiology C SPUT  Normal oral flora present Oct-21-2022 0522 Microbiology MRSA  No methicillin resistant staphylococcus aureus isolated after one night incubation. Oct-20-2022 2045 Serology PROCALC  2.66 Oct-20-2022 2045 Chemistry LACTATE  1.40 Oct-20-2022 1925 Urinalysis Department SPECGRAV  1.015U-PH  6.0LEUCOCYT  ModerateNITRITES  NegativePROTEIN  NegativeGLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  SmallCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  YWBC  *10-15RBC  *0-2SQUAM EP  NoneBACTERIA  *TraceMUCUS  NoneOTHER  Yeast Oct-20-2022 1925 Microbiology C UR  After two nights of incubation Oct-20-2022 1835 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  NCVDEMPHC  NCVDSYMP  NCVDSYMDT  UCVDHOSP  NCVDICU  NCVDRESID  YCVDPREG  N Oct-20-2022 1600 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Oct-20-2022 1513 Hematology WBC  16.1RBC  4.07HGB  11.8HCT  35.8MCV  88.0MCH  29.0MCHC  33.0RDW  15.1RDWSD  48.4PLT  282MPV  10.3AUTONEU%  85.5AUTOLYM%  5.9AUTOMON%  8.0AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  13.8AUTOLYM#  1.0AUTOMON#  1.3AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.08IG%  0.5 Oct-20-2022 1513 Chemistry GLUCOSE  114BUN  20CREAT  1.7MDRD GFR  38NA  136K  4.6CL  101CALCIUM  8.4ALK PHOS  112CO2  24.2AST  25ALT  23AST/ALT  1.1TL PROT  6.5ALBUMIN  2.8TBILI  0.7OSMO  275.4ANION GP  15.4BUN/CRE  11.8CRP  3.10TROPI-HS  56 Oct-20-2022 1513 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Imaging Results xray Single view of the chest.Date of Exam: 10/20/2022. COMPARISON: 09/29/2022. FINDINGS: Severe left and mild-moderate right lung consolidation most consistent with multifocal pneumonia. Recommend radiographic follow-up to complete resolution. Heart size is within normal limits. No pulmonary edema. No pneumothorax. Aortic atherosclerosis. IMPRESSION: Severe left and mild-moderate right lung consolidation most consistent with multifocal pneumonia. Recommend radiographic follow-up to complete resolution. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD   CT Chest without contrast. Date of Exam: 10/21/2022. COMPARISON: Chest CT 11/08/2021. FINDINGS: Lungs: Moderate left upper and left lower lobe consolidation with multiple new nodular opacities. Mild bilateral bronchial wall thickening. Small right lung base pulmonary opacities. Findings are consistent with multifocal pneumonia. Recommend 3-month chest CT follow-up to ensure no new pulmonary nodules have developed since prior exam. No pulmonary edema. Small calcified pulmonary granulomas. The evaluation for possible noncalcified pulmonary nodules is severely limited by pneumonia. Pleural space: Small bilateral pleural effusions. No pneumothorax. Heart: Severe coronary artery calcifications. No pericardial effusion. Heart size within normal limits. Mediastinum: Esophagus is mildly distended. Debris and fluid within the majority of the thoracic esophagus. Differential considerations include esophageal dysmotility, gastroesophageal junction stenosis, or gastroesophageal reflux. No pneumomediastinum. Bones/joints: Mildly displaced subacute sternal body fracture is new since 2021. Multiple subacute healing nondisplaced bilateral anterior rib fractures. No acute fractures. Soft tissues: Stable bilateral gynecomastia Vasculature: Atherosclerosis. Thoracic aorta is normal in caliber. No thoracic aortic aneurysm. Lymph nodes: Calcified mediastinal and hilar lymph nodes. No pathologically enlarged noncalcified lymph nodes. Liver: Indeterminate superior right lobe liver hypoattenuation lesion measuring 2.5 cm has decreased in size since prior exam. Calcified liver granulomas. Spleen: Calcified splenic granulomas. Kidneys and ureters: Right renal cyst. IMPRESSION: 1. Moderate left upper and left lower lobe consolidation with multiple new nodular opacities. Mild bilateral bronchial wall thickening. Small right lung base pulmonary opacities. Findings are consistent with multifocal pneumonia. Recommend 3-month chest CT follow-up to ensure no new pulmonary nodules have developed since prior exam. 2. Small bilateral pleural effusions. 3. Esophagus is mildly distended. Debris and fluid within the thoracic esophagus. Differential considerations include esophageal dysmotility, gastroesophageal junction stenosis, or gastroesophageal reflux. 4. Severe coronary artery calcifications. 5. Indeterminate superior right lobe liver hypoattenuation lesion measuring 2.5 cm has decreased in size since prior exam. 6. Stable bilateral gynecomastia. 7. Mildly displaced subacute sternal body fracture is new since 2021. Multiple subacute healing nondisplaced bilateral anterior rib fractures. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD  Echo complete no dye, 10/21/2022 Findings Left Ventricle: Normal left ventricular systolic function with LVEF >60%. Impaired relaxation (Grade I diastolic dysfunction). Left Atrium: Mild left atrial enlargement which is consistent with LA index volumes between 35 - 41 cm2. Mitral Valve: Mild mitral regurgitation. Aortic Valve: Mild aortic stenosis (AVA > 1.5 cm2). Right Ventricle: Normal right ventricular systolic function. Mild enlargement of right ventricle. Right Atrium: Severely enlarged RA that measures > 50mm. Atrial Septum: Normal atrial septum. Tricuspid Valve: Moderate tricuspid regurgitation. The estimated Peak RVSP is 52 mmHg. Pulmonic Valve: Normal pulmonic valve appearance and function with trivial (physiologic) regurgitation. IVC: Dilated inferior vena cava with respiratory collapse only with sniff. Aorta: Aortic root size is normal. Pericardium: Normal pericardium with no significant pericardial effusion. Conclusions Normal left ventricular systolic function with LVEF >60%. Impaired relaxation (Grade I diastolic dysfunction). Mild left atrial enlargement which is consistent with LA index volumes between 35 - 41 cm2. Mild mitral regurgitation. Mild aortic stenosis (AVA > 1.5 cm2). Moderate tricuspid regurgitation. The estimated Peak RVSP is 52 mmHg. Electronically Signed By: D.O.  Chest x-ray, 10/23/2022 FINDINGS: Stable bilateral pulmonary opacities consistent with multifocal pneumonia. Stable heart size which is mildly enlarged. No pneumothorax. Stable small left pleural effusion. IMPRESSION: Stable chest. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD  Functional Status* Activity of daily living - Needs assistance (resident of pines SNF)  Mental Status* Normal Cognition  Social History tobacco use Never Smoked, Smoking Cessation Not Applicable  marital status Widowed Wife passed away October 2019  Health Concerns Insomnia  Gastroesophageal reflux disease  Paroxysmal atrial fibrillation  HTN (hypertension)  Anxiety  Hyperlipidemia  Pneumonia  Sepsis  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Oct-24-2022 0810 T 96.9 HR 98 RR     23 BP   126 / 77 O2Sat 95 Oct-24-2022 0400 HR 72 RR     22 BP   105 / 55 O2Sat 96 Oct-24-2022 0351 T 97.8 PHYSICAL EXAM CONSTITUTIONAL: Patient appears comfortable and in no acute distress. CARDIOVASCULAR:  atrial fibrillation rate controlled, HR 72,   auscultation reveals irregularly irregular without murmur or accessory sounds. pulses are 2/2 in the upper extremities, no edema noted RESPIRATORY: Lungs clear to auscultation throughout and respiratory effort is non-labored.   poor excursion,  breaths shallow but normal rate GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive NEUROLOGICAL: Patient is alert and generally oriented. Sensation is grossly intact PSYCHIATRIC: Patient's mood is euthymic, affect is appropriate. RASS of 0.  Hospital Course Patient is a 91 yr old male who presented to the ED from Nursing home today for general weakness. PMH includes anemia, BPH, chronic urinary retention, indwelling urinary catheter, hyperlipidemia, hypertension, BPH, history of cardiac arrest 2 months ago, and history of TIA. The patient was diagnosed with COVID-19 on 10/08/2022 prior to admission. The patient was originally admitted to the Nursing Home for rehabilitation to home following an MI and cardiac arrest 2 months ago. The patient was found to have left lobar pneumonia with with possible patchy infiltrate superimposed, patient has community-acquired pneumonia and patchy infiltrate is either evidence of recent COVID or continued active COVID. He was treated as active COVID while hospitalized. The patient was originally treated with 3 days of Zosyn and is being discharged with 2 days of Augmentin and doxycycline, sputum cultures were negative we are treating based on empiric guidelines. The patient's hospital stay was significant for acute respiratory failure, received supplemental oxygen for 3 days. A yeast urinary tract infection indwelling catheter associated, which is being treated for urinary tract infection. The patient had persistent low magnesium likely due to low dietary intake and PPI use this was replaced via IV magnesium. The patient continued to improve throughout his hospital stay and the patient was deemed ready to be discharged today to the Nursing Home.  Condition at Discharge Stable  Discharge Medications Acetaminophen Oral Tablet 325 MG 650 MG ORALLY EVERY 4 HOURS AS NEEDED for MILD PAIN (1-3 ON PAIN SCALE) Amoxicillin-Pot Clavulanate Oral Tablet 875-125 MG 1 TAB ORALLY TWICE DAILY (Printed by DO on Oct-24-2022 1023) Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT 100 MCG INHALATION ONCE A DAY Doxycycline Hyclate Oral Capsule 100 MG 100 MG ORALLY TWICE DAILY (Printed by DO on Oct-24-2022 1023) Eliquis Oral Tablet 2.5 MG 0.5 MG ORALLY TWICE DAILY Famotidine Oral Tablet 20 MG 20 MG ORALLY DAILY AT BEDTIME FLUCONAZOLE 150 MG ORALLY ONCE A DAY (Printed by DO on Oct-24-2022 1023) guaiFENesin AC Oral Syrup 100-10 MG/5ML 100 MG ORALLY EVERY 4 HOURS AS NEEDED for COUGH Lidocaine External Patch 4 % 1 PAT TRANSDERMAL TWICE A DAY AS NEEDED for MODERATE-SEVERE (PAIN 6-10) Melatonin Oral Capsule 3 MG 3 MG ORALLY DAILY AT BEDTIME Metoprolol Tartrate Oral Tablet 25 MG 12.5 MG ORALLY TWICE DAILY Milk of Magnesia Oral Suspension 400 MG/5ML 400 MG ORALLY EVERY 24 HOURS AS NEEDED for CONSTIPATION Mylanta Maximum Strength Oral Suspension 400-400-40 MG/5ML 30 ML ORALLY EVERY 4 HOURS AS NEEDED for CONSTIPATION Nitroglycerin Sublingual Tablet Sublingual 0.4 MG 0.4 MG ORALLY EVERY 5 MINUTES AS NEEDED for CHEST PAIN Omeprazole Oral Capsule Delayed Release 20 MG 20 MG ORALLY ONCE A DAY oxyCODONE HCl Oral Capsule 5 MG 2.5 MG ORALLY TWICE A DAY AS NEEDED for MODERATE-SEVERE (PAIN 6-10) Sennosides-Docusate Sodium Oral Tablet 8.6-50 MG 8.6 MG ORALLY TWICE A DAY AS NEEDED for CONSTIPATION Tamsulosin HCl Oral Capsule 0.4 MG 0.4 MG ORALLY ONCE A DAY traZODone HCl Oral Tablet 50 MG 50 MG ORALLY DAILY AT BEDTIME Discharge Disposition Transfer to skilled nursing facility (SNF)  Plan FINAL DIAGNOSES: - Community-acquired bacterial pneumonia, left lower lobe,  with COVID-19 infection tested positive on 10/08/22, improved - Urinary tract infection, secondary to candida, moderate leukocytes and trace bacteria on admission, improved - Hypoalbuminemia, chronic, stable at 2.3 on 10/23, likely secondary to poor oral intake - Elevated CRP, secondary to pneumonia vs UTI, improved - Normocytic anemia, chronic,  persistent - Hypomagnesemia, acute, new, Mg 1.7  persistent - Benign prostatic hyperplasia, chronic,  with outflow obstruction - Chronic Urinary Retention, secondary to BPH - Personal use of chronic indwelling Foley,   secondary to chronic urinary retention  - Atrial fibrillation persistent, chronic, rate controlled with metoprolol,  not rhythm controlled chronic - Chronic kidney disease, stable, stage 3b, Cr 1.7, GFR 38 on admission (10/20/2022), Cr 1.5, GFR 44 on 10/23 - History of sudden cardia arrest 2 months ago - History of TIA, no residual effects - Sepsis acute, secondary to COVID pneumonia vs UTI, Resolved, HR>90, RR>20, WBC>12 on admission (10/20/2022), HR 87, RR 24, WBC 11.3 on 10/21/2022  Plan:  The patient was deemed stable and ready for discharge to the Nursing Home, were patient is a long-term resident.  We are discharging the patient on amoxicillin clavulanic acid 875  p.o. b.i.d.  and doxycycline 100 mg p.o. b.i.d. for 2 days to finish out a 5 day course of treatment for his community-acquired pneumonia. The patient received 3 days of Zosyn while hospitalized. COVID-19 is likely a secondary infection but not the primary source of his pneumonia.  Patient is being discharged with 13 days of fluconazole for yeast UTI  associated with his indwelling Foley.   I called Nursing Home today to confirm that the patient does require indwelling Foley for the diagnosis of urinary retention and those were added to his assessment last. patient is being discharged with a Foley that was placed while he was hospitalized.   We are continuing all other home medications without alteration. Follow-up will be done within 7 days by Dr. at the nursing home.    The patient was seen by attending Dr. and the plan of care discussed with this resident.    Primary Care Provider DO  Electronically signed by DO on Oct-24-2022 1116