Age: 49.0
Sex: M
Vaccine: COVID19
Symptoms: Haematochezia, Haematocrit, Haemoglobin normal, Hyperlipidaemia, Hypoxia
Clinical narrative: Date of Admission:  9/13/2023    Date of Discharge:  9/16/2023    Primary Care Physician:  MD   Pending Study Results at Discharge: Cultures   Issues to be Addressed in Follow-up:   1) continued fluid restriction and diuresis at home.   2) continue optimization of CHF management and fluid status as outpatient   3) patient was referred to CHF Home telemonitoring as outpatient     Reason for Hospital Admission (Admitting Diagnosis):  chf exacerbation/covid    HPI on admission:   Patient is a 51 Y male with a history of CHF, asthma, non ischemic dilated cardiomyopathy, HTN, atrial fibrillation, DM2, sleep apnea, CAD who presented from home for persistent DOE and chest pain.  Patient was recently seen in the ED diagnosed with COVID and had been taking Paxlovid. He was discharged from the ED. He still did not feel well and tried to see his PCP. PCP sent to the ED cause of heavy breathing.  Mainly DOE. Laying flat made his breathing worse. He sleeps on lounge chair due to orthopnea., that has been worsening in the last 4weeks. Has been watching salt and water intake. Denies fevers, chills, sore throat, diarrhea, lightheadedness or dizziness.  Has dry cough. Chest pressure when walking, feels like he has tightness in chest and neck otherwise no pain.  and abdominal pressure Is constant. Nothing makes it better, anything he does makes it worse. Eating, or drinking makes it worse. It makes him feel like he has to burp and he feels he can't.  No increased need to urinate or burning when urinating. Can't urinate as much since the last 3-4 weeks ago, noticed lasix not working like it used to.  No weight gain, lost 15 lbs in 4 weeks. Appetite is unremarkable. Has been having bloody stools wth plans for colonoscopy soon.    He complains of intermittent blood stools and has been seen by PCP for workup of that.  He has not been able to make urine Even after lasix.   Hospital Course:   Patient was initially admitted for chest pain and shortness of breath, acute ACS was ruled out, patient was found to have acute CHF exacerbation.  Patient was diagnosed with COVID on 9/11/2023 before presentation to the ER.  Given new hypoxemia, patient was started on remdesivir and Decadron.  Patient was also started on IV Lasix with good fluid output.  Patient was diuresed a total of 4 L and was quickly weaned off of oxygen.  Patient returned to his baseline respiratory status and was discharged home for continued diuresis down to dry weight of 380.  Patient was referred to CHF Home telemonitoring upon discharge and was given instructions for fluid restriction of 1 L/day.  We will follow-up with primary care and cardiology as outpatient for further optimization of CHF management and diuresis.  Given resolution of acute hypoxemic respiratory failure remdesivir and Decadron were discontinued, patient can continue Paxlovid as outpatient.  We will follow-up with primary care for optimization of other medical issues.   Significant Findings:    Please see above   Hospital Course By Problem: Patient Active Hospital Problem List:  HEART FAILURE W REDUCED LVEF 31-40%, UNSPECIFIED ACUITY (12/4/2019)  HTN (HYPERTENSION) (4/29/2017)  NONISCHEMIC DILATED CARDIOMYOPATHY (12/4/2019)  ATRIAL FIBRILLATION, UNSPECIFIED (2/5/2020)  CAD (CORONARY ARTERY DISEASE) WO ANGINA (4/8/2022) CONGESTIVE HEART FAILURE WITH REDUCED  EJECTION FRACTION     Assessment:  - Respiratory status now back to baseline, weaned off of oxygen - I/O total for admission: -3.9 L - BP 109/70  | Pulse 65  | Temp 97.8 °F (36.6 °C)  | Resp 20  | Ht 6' 1"  | Wt 176.6 kg (389 lb 5.3 oz)  | SpO2 98%  | BMI 51.37 kg/m²   Weight Readings(Last 3)      9/15/2023 9/15/2023 9/16/2023       *: 176.6 kg (389 lb 4.8 oz) 176.4 kg (389 lb) 176.6 kg (389 lb 5.3 oz)        Lab Results Component Value Date   B type natriuretic protein 643 (H) 09/13/2023   B type natriuretic protein 669 (H) 09/11/2023   B type natriuretic protein 575 (H) 09/06/2023    Lab Results Component Value Date   Troponin I 0.02 05/15/2022   Troponin I 0.04 01/26/2022   Troponin I 0.04 12/21/2021   TROPONIN I, HIGH SENSITIVITY 24 (H) 09/13/2023   TROPONIN I, HIGH SENSITIVITY 30 (H) 09/13/2023   TROPONIN I, HIGH SENSITIVITY 25 (H) 09/11/2023    Lab Results Component Value Date   Creatinine 1.52 (H) 09/16/2023   Creatinine 1.35 (H) 09/15/2023   Creatinine 1.41 (H) 09/14/2023      Plan:  - Change Lasix to 80 mg QD - Strict Intake and Output, Daily wt, Fluid Restriction - Continue Coreg 12.5 mg twice daily - HOLD lisinopril 40 mg daily, f/u as outpatient for timing of restart   - Resume Sprinolactone 12.5 mg QD - f/u Home Tele-monitoring on discharge - Goal wt 380 - f/u TTE - Plan for DC home today   ASTHMA, UNSPECIFIED (11/8/2019)   Assessment: Noted stable   Plan: Continue Alvesco twice daily Flonase daily, albuterol as needed   DM 2 W HYPERLIPIDEMIA (5/19/2021)  DIABETES MELLITUS   Assessment:   Lab Results Component Value Date   Hgb A1c % 7.1 (H) 08/15/2023    Lab Results Component Value Date   GLUCOSE, RANDOM 157 09/16/2023   GLUCOSE, RANDOM 146 09/15/2023   GLUCOSE, RANDOM 132 09/14/2023    GLUCOSE, BLOOD, GLUCOMETER Date/Time Value Ref Range Status 09/16/2023 0822 150 60 - 159 mg/dL Final     Comment:     Pre-meal 09/15/2023 2054 196 (H) 60 - 159 mg/dL Final 09/15/2023 1700 231 (H) 60 - 159 mg/dL Final     Comment:     Pre-meal 09/15/2023 1228 208 (H) 60 - 159 mg/dL Final     Comment:     Pre-meal 09/15/2023 0753 134 60 - 159 mg/dL Final 09/14/2023 2110 209 (H) 60 - 159 mg/dL Final 09/14/2023 1135 180 (H) 60 - 159 mg/dL Final      Plan:  - Continue ISS - Continued optimization as outpatient     ELEVATED CREATININE (8/18/2023)  CKD (CHRONIC KIDNEY DISEASE) (9/15/2023)  CKD   Assessment:  - estimated creatinine clearance is 96.4 mL/min (A) (based on SCr of 1.52 mg/dL (H)). -   Lab Results Component Value Date   Creatinine 1.52 (H) 09/16/2023   Creatinine 1.35 (H) 09/15/2023   Creatinine 1.41 (H) 09/14/2023   - Cr at recently established baseline    Plan:  - Avoid nephrotoxins - Risk factor reduction - Continue to monitor Cr - Monitor while on diuretics - Continued optimization as outpatient   COVID-19 DISEASE, PERSON UNDER INVESTIGATION (8/14/2020)   Assessment: Positive on 9/11/2023, was taking Paxil but as outpatient   Plan: Will DCContinue remdesivir and Decadron given weaned off of Oxygen   RECTAL BLEEDING (8/28/2023)  RECTAL MASS (8/28/2023)   Assessment:   Lab Results Component Value Date   Hgb 13.4 09/16/2023   Hgb 13.6 09/15/2023   Hgb 13.2 09/14/2023   Hematocrit 42.8 09/16/2023   Hematocrit 44.2 09/15/2023   Hematocrit 42.5 09/14/2023    Plan:  - H&H stable - Previous plan was for outpatient colonoscopy 10/4/23, no acute indication for urgent colonoscopy -Continue with outpatient colonoscopy as previously planned   SEVERE OBESITY (BMI >= 40) (11/18/2019)   Assessment: noted   Plan: wt loss, lifestyle changes, further management via PCP   SLEEP APNEA (7/23/2021)   Assessment: Noted   Plan: CPAP during sleeping hours       Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) HEART FAILURE W REDUCED LVEF 31-40%, UNSPECIFIED ACUITY   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA   ? ATRIAL FIBRILLATION, UNSPECIFIED       While pericardial drain was in place.  No other episodes   ? NONISCHEMIC DILATED CARDIOMYOPATHY       12/16/2019 Cardiac Cath: 1. Minimal, non-obstructive CAD.  2. Elevated LVEDP 28mmHg at LVOT  3. Elevated right heart pressures - mean RA 15, RV 48/11, PA 45/23 (mean  32), PCW mean 27  4. CI 2.5-3.6 L/min/m2 (Thermal-fick)   ? HTN (HYPERTENSION)   ? DM 2 W HYPERLIPIDEMIA   ? ASTHMA, UNSPECIFIED   ? CKD (CHRONIC KIDNEY DISEASE)   ? ELEVATED CREATININE   ? COVID-19 DISEASE, PERSON UNDER INVESTIGATION   ? RECTAL BLEEDING       Added automatically from request for surgery     ? RECTAL MASS       Added automatically from request for surgery     ? SLEEP APNEA       AHI 22/hr (WatchPAT ), %time < 90%: 8.9%, Moderate  - 7/23/2021     ? SEVERE OBESITY (BMI >= 40)     Resolved Hospital Problems No resolved problems to display.     Primary Procedures:  None      Secondary Procedures: None   Consults:  None   Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code     Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).      Procedures/Surgical Case  Oct 04, 2023 COLONOSCOPY DIAGNOSTIC with (D.O.)             DO   9/16/2023 10:30 AM              Note Details  Author  (D.O.) File Time 9/16/2023 12:10 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor  (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/13/2023  ED to Hosp-Admission (Discharged) on 9/13/2023  ED to Hosp-Admission (Discharged) on 9/13/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HEART FAILURE W REDUCED LVEF 31-40%, UNSPECIFIED ACUITY  HTN (HYPERTENSION)  ASTHMA, UNSPECIFIED  SEVERE OBESITY (BMI >= 40)  NONISCHEMIC DILATED CARDIOMYOPATHY  DM 2 W HYPERLIPIDEMIA  SLEEP APNEA  CAD (CORONARY ARTERY DISEASE) WO ANGINA  CKD (CHRONIC KIDNEY DISEASE)  COVID-19 DISEASE, PERSON UNDER INVESTIGATION  ELEVATED CREATININE  RECTAL BLEEDING  RECTAL MASS  ATRIAL FIBRILLATION, UNSPECIFIED Care Timeline  09/14   Admitted from ED (Observation) 0328 09/16   Discharged 1425  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 9/16/2023) Medication List at Discharge   albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply is 1 canister  blood sugar diagnostic 1 Strip Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  Patient not taking:  Reported on 9/14/2023  blood-glucose control, normal Use as directed with blood glucose meter  Patient not taking:  Reported on 9/14/2023  blood-glucose meter Use as directed to test blood sugar  Patient not taking:  Reported on 9/14/2023  carvedilol 12.5 mg Take 1 and one-half tablets by mouth every morning AND take 1 and one-half tablets by mouth every evening.  ciclesonide 160 mcg/actuation 1 Puff Inhalation 2 TIMES A DAY, for asthma prevention and control. Rinse mouth well after use  docusate sodium 100 mg Take 1 to 2 capsules by mouth at bedtime as needed for constipation  epinephrine 0.3 mg/0.3 mL Inject 0.3 mL intramuscularly as needed for severe allergic reaction . Inject into thigh at the first sign of severe allergic reaction or as directed  fluticasone propionate 50 mcg/actuation USE 2 SPRAYS IN EACH NOSTRIL DAILY FOR 1 WEEK, THEN MAY ADJUST TO 1 OR 2 SPRAYS IN EACH NOSTRIL DAILY  furosemide 80 mg Oral DAILY  hydrocortisone 2.5 % Insert rectally 2 times a day as directed for hemorrhoids  lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  Patient not taking:  Reported on 9/14/2023  lidocaine 5 % Apply to affected area(s) 2 to 3 times a day for fissure pain  nirmatrelvir/ritonavir 150-100 mg Take 150 mg Nirmatrelvir (1 of 150 mg tablet) with 100 mg Ritonavir (1 of 100 mg tablet) by mouth 2 times a day for 5 days  nitroglycerin 0.4 mg Sublingual ONE TIME, . May repeat 2 times every 5 minutes. Call 911 if pain persists longer than 5 minutes after the first dose. Continue to take the 2nd and 3rd doses if pain persists  oxycodone HCl 5 mg Oral EVERY 6 HOURS AS NEEDED  sennosides 8.6 mg Take 2 tablets by mouth 2 times a day as needed for constipation . NOTE: Change in strength and directions due to medication availability.  simethicone 160 mg Oral 2 TIMES A DAY, - THIS IS SIMETHICONE - On the day of your procedure, chew and swallow 2 tablets before your liquid prep and then chew and swallow 2 tablets after your prep.  spironolactone 12.5 mg Oral DAILY  wheat dextrin 3 gram/3.5 gram Dissolve 2 teaspoonsful with 8 ounces of any beverage or soft food. Take by mouth up to 3 times a day as needed for constipation. Do not exceed 6 teaspoonsful in 24 hours. Carbonated beverages are not recommended