Sex: F
Vaccine: UNK
Symptoms: White blood cell count decreased
Clinical narrative: (M.D.)  Physician Specialty:  Hospital Medicine Discharge Summary     Addendum  Addendum    Addendum: SNF discharged delayed due to bed availability.  Patient discharged 11/12/23. See progress note for 11/12 for more details.   MD   11/12/2023 10:56 AM       DISCHARGE SUMMARY    Date of Admission:  11/7/2023   Date of Discharge:  11/11/2023    Issues to be Addressed at Follow-up:  --outpatient labs ORDERED to be followed up: CBC/ chem7 ordered via SNF   --reassess GI symptoms/ pain control --follow up with surgery as outpatient for coloscopy and biliary drain care  --patient being discharged with foley due to urinary retention, please obtain voiding trial at SNF  --discharged with oral bicarb, if repeat chem7 ordered for next week with resolved metabolic acidosis, please stop the medication  --prescribed ultram due to intermittent postoperative abdominal pain, please titrate off in future  --reassess volume status (patient with EF of 30%, minimal oral intake so not on diuretics); reassess nutritional state (consider megace or Remeron in future) --follow up labs/images pending at discharge:   Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/7/2023  8:41 PM BLOOD CULTURE 2 Preliminary BLOOD   11/7/2023  8:41 PM BLOOD CULTURE Preliminary BLOOD     Consults:  --surgery  --palliative care    Primary Procedures:  None    Hospital Course:  Reason for Hospitalization: Patient is a 79 Y female with history of systolic CHF with EF 30%, coronary artery disease, recent hospitalization for perforated diverticulitis (now with colostomy) and cholecystitis (now with external biliary drain), Bacteriodes bacteremia (treated with Unasyn and Augmentin) presented from SNF with acute kidney injury/ metabolic acidosis and covid 19 positive.    Hospital Course and Significant Findings: Patient Active Hospital Problem List:  HYPERKALEMIA (11/7/2023)  NONTRAUMATIC ACUTE KIDNEY INJURY (10/19/2023)  CKD (CHRONIC KIDNEY DISEASE) (11/7/2023)   Assessment: patient with acute kidney injury on CKD, now creatinine at baseline; likely due to poor oral intake/ prerenal state; diet intake now around 50%. Noted associated hypomagnesemia (despite CKD).   Hyperkalemia resolved.    Plan:  -continue to encourage oral intake -chem7 repeat ordered for next week at SNF along with Mg (prescribed oral Mg before bedtime, stop if Mg normalizes)    HX OF MI, UNSPECIFIED TYPE (3/17/2012)  CAD (CORONARY ARTERY DISEASE) (3/17/2012)  PRESENCE OF STENT, CORONARY ARTERY (3/17/2012)  ELEVATED TROPONIN I (11/7/2023)   Assessment: no ischemic symptoms    Plan:  -patient instructed to restart taking aspirin/ coreg -continue to monitor symptoms     HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY (3/20/2012)   Assessment: noted, euvolemic   Plan: monitor off diuretics     DIVERTICULITIS OF SIGMOID W PERFORATION (10/19/2023)  PRESENCE OF COLOSTOMY (10/20/2023)   Assessment: seen by surgery for mucosal separation and they recommend wound care alone. Biliary drain in proper position on CT scan with good drainage.    Plan:  -follow up outpatient surgery for colonoscopy/ biliary drain care  -patient still with intermittent incisional pain (incision well healing); prescribed ultram as needed and Zofran/ compazine as needed for intermittent nausea  -I have not consulted the database because the patient was seen in the emergency department and I have prescribed no more than a non-refillable 7-day supply.    SEVERE PROTEIN CALORIE MALNUTRITION (10/29/2023)   Assessment: noted   Plan:  -continue dietician assessment and encourage oral intake; could consider megace or remeron in future  -continue IBS/ gluten free diet    RIGHT COMMON ILIAC ARTERY ANEURYSM (11/7/2023)   Assessment: noted, as noted on CT scan    Plan: continue beta-blocker     COVID-19 DISEASE (11/7/2023)   Assessment: noted, asymptomatic    Plan: precautions as per SNF     HYPONATREMIA (11/7/2023)   Assessment: resolved with IVF    Plan: chem7 as outpatient    ELEVATED SERUM LIPASE (11/7/2023)   Assessment: likely due to CKD and reduced lipase clearance,    Plan: pancreas appears normal on CT scan; no further work up    METABOLIC ACIDOSIS, UNSPECIFIED (11/7/2023)   Assessment: acute kidney injury vs due to colostomy with bicarb losses, improved   Plan: discharged with oral sodium bicarb, repeat lab work next week    URINARY RETENTION (11/11/2023)   Assessment: noted   Plan: patient being discharged with foley, obtain voiding trial at SNF    ABNL URINALYSIS FINDING (11/11/2023)   Assessment: patient is asymptomatic, urine culture with candida kresei    Plan: monitor for symptoms    Medications, instructions, follow up information: please see patient's discharge instructions/ AVS.   BP 107/60  | Pulse 82  | Temp 98.4 °F (36.9 °C)  | Resp 18  | SpO2 96%  | Breastfeeding No  Physical Exam: SUBJECTIVE: mild nausea but no vomiting, minimal abdominal pain; appetite not great but trying, weak all over (unchanged), brown stool in colostomy  General: Alert, not in distress  HEENT: moist mucous membranes, neck supple  Cardiac: Regular rate and rhythm   Pulm: Clear to auscultation bilaterally.  No wheezes or crackles.  Abdomen:  Midline surgical incision with staples (clean/dry/intact), RUQ biliary drain without purulence or discharge, left LQ colostomy with brown/formed stool Extremities: no lower extremity edema , pulses palpable in lower extremiti Mental Status: A&Ox3 (name, date, location)  Neuro: CN 2-12 grossly intact, moves all extremities on command    Pertinent Imaging studies: CT abdomen/pelvis:   1. Small volume free fluid in the left paracolic gutter, decreased in the interval. No organized fluid collection.  2. Cholecystostomy drain is within the gallbladder.  3. Unchanged 2.8 cm right common iliac artery aneurysm     PANCREAS: Normal.   Echocardiogram 10/18/23 ?  Left Ventricle: Left ventricle is moderately dilated. Mild concentric hypertrophy present. The LV is spherically remodeled Severely reduced systolic function with an estimated EF of 25 - 30%. The septum and apex are hypokinetic, suggestive of LAD territory CAD.  Septal motion is consistent with interventricular conduction delay. ?  Right Ventricle: Right ventricle size is normal. Normal systolic function. ?  Pericardium: Small circumferential pericardial effusion present. No evidence of cardiac tamponade. ?  Normal (<2.1 cm) IVC size with less than 50% collapse, estimated right atrial pressure of 8 mmHg (intermediate).    Recent Labs   11/11/23 0530 11/10/23 0607 11/09/23 0249 11/08/23 2012 11/08/23 1445 NA 135 137 137 136 138 K 4.1 4.0 3.8 4.2 4.2 CO2 20* 22* 21* 19* 13* CL 106 104 104 104 116* BUN 52* 62* 75* 78* 58* CR 1.88* 2.00* 2.41* 2.59* 1.79* RBS 84 92 100 106 74 CA 7.7*  --   --   --   --  PHOS 4.3  --   --   --   --  MG 1.2*  --   --   --   --       Recent Labs   11/11/23 0530 11/10/23 0607 11/09/23 0249 11/08/23 0546 11/07/23 0620 WBC 5.7 5.1 5.9 4.8 6.8 HGB 8.9* 8.6* 8.2* 9.0* 8.7* HCT 28.7* 26.9* 27.0* 28.9* 29.0* PLT 306 313 358 334 394 MCV 92 89 91 92 97   Complications:  none    Condition on Discharge:  stable    Code Status: Do Not Resuscitate    Discharge Disposition:  SNF    Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) HYPERKALEMIA   ? HX OF MI, UNSPECIFIED TYPE       Acute STEMI, Unspecified<< Resolved noted by (M.D.)on 6/14/2021   ? HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY       ischemic cardiomyopathy   ? PRESENCE OF STENT, CORONARY ARTERY       Proximal LAD lesion treated using an OTW Integrity BMS 3.5 X 18 mm stent post dilated to 4.0 mm using a 4.0 X 12 non compliant balloon. Ostial Diagonal lesion treated using a 2.5 X 12 mm OTW balloon. aspirin lifelong and Plavix daily for one year     ? CAD (CORONARY ARTERY DISEASE)       Acute anterior wall STEMi with 99% proximal thrombotic LAd lesion   ? URINARY RETENTION   ? ABNL URINALYSIS FINDING   ? RIGHT COMMON ILIAC ARTERY ANEURYSM   ? CKD (CHRONIC KIDNEY DISEASE)   ? COVID-19 DISEASE   ? HYPONATREMIA   ? ELEVATED TROPONIN I   ? ELEVATED SERUM LIPASE   ? METABOLIC ACIDOSIS, UNSPECIFIED   ? SEVERE PROTEIN CALORIE MALNUTRITION   ? PRESENCE OF COLOSTOMY   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? DIVERTICULITIS OF SIGMOID W PERFORATION     Resolved Hospital Problems No resolved problems to display.   MD        Note Details  Author (M.D.) File Time 11/12/2023 10:57 AM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 11/7/2023  ED to Hosp-Admission (Discharged) on 11/7/2023  ED to Hosp-Admission (Discharged) on 11/7/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Forms:   STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   PRESENCE OF COLOSTOMY  SEVERE PROTEIN CALORIE MALNUTRITION  RIGHT COMMON ILIAC ARTERY ANEURYSM  CKD (CHRONIC KIDNEY DISEASE)  HYPERKALEMIA  DIVERTICULITIS OF SIGMOID W PERFORATION  NONTRAUMATIC ACUTE KIDNEY INJURY  COVID-19 DISEASE  HYPONATREMIA  ELEVATED TROPONIN I  ELEVATED SERUM LIPASE  METABOLIC ACIDOSIS, UNSPECIFIED  URINARY RETENTION  ABNL URINALYSIS FINDING  HX OF MI, UNSPECIFIED TYPE  CAD (CORONARY ARTERY DISEASE)  HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY  PRESENCE OF STENT, CORONARY ARTERY Care Timeline  11/07   Admitted from ED (Observation) 1039 11/10   Admitted 0831 11/12   Discharged 1023  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 11/12/2023) Medication List at Discharge   acetaminophen 500 mg Oral EVERY 4 HOURS AS NEEDED  aspirin 81 mg Oral DAILY  carvedilol 3.125 mg Oral 2 TIMES A DAY  famotidine 20 mg Oral DAILY  magnesium chloride 143 mg Oral EVERY BEDTIME  ondansetron HCl 4 mg Oral 3 TIMES A DAY AS NEEDED  prochlorperazine maleate 5 mg Oral 3 TIMES A DAY AS NEEDED  sodium bicarbonate 650 mg Oral 3 TIMES A DAY AFTER MEALS  tramadol HCl 25 mg Oral EVERY 8 HOURS AS NEEDED PT in house Bed also not showing pt was vaccinated