Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Decreased appetite, Essential hypertension, Hypoxia, Malaise, Pyrexia
Clinical narrative: Signed    Date of Admission: 11/26/2023   Date of Discharge: 11/28/2023   Issues to be Addressed at Follow-up: Any ongoing signs of infection?   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/27/2023  2:10 PM BLOOD CULTURE 2 In process BLOOD   11/27/2023  2:05 PM BLOOD CULTURE In process BLOOD   11/26/2023  9:48 PM BLOOD CULTURE 2 Preliminary BLOOD   11/26/2023  9:33 PM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? HX OF STROKE         11/8/2021 - DOV S: hx of CVA in 2019      On secondary prevention measures      HTn control , cholesterol control  A/P: restart ASA 81 mg           Cont Bp control with amlodipine           Atorvastatin 20mg for secondary prevention           Check A1c      ? ESSENTIAL HTN         11/8/2021 - DOV S: taking x 2 years  O: rrr, s1 and s2      CTAB  A/P: well controlled on amlodipine        Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 69 Y male with pmh of mild cognitive impairment, HYPERTENSION, HLP h/o CVA who presented to the ED with fever, confusion, malaise, poor appetite.  Pt with covid pneumonia, mild hypoxemia (sats low 90's on RA.   given  remdesivir and decadron.  RA sat 94%.  Pt stable for discharge to B and C.     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  covid pneumonia   Complications: none   Consults:  HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     Note Details  Author (M.D.) File Time 11/28/2023  2:40 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Critical Care Medicine  Admit Date 11/26/2023  ED to Hosp-Admission (Discharged) on 11/26/2023  ED to Hosp-Admission (Discharged) on 11/26/2023   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   ESSENTIAL HTN  COVID-19 PNEUMONIA  HX OF STROKE Care Timeline  11/27   Admitted from ED (Observation) 1310 11/28   Discharged 1831  Discharge   Assisted Living Facility or Board & Care or Residential Care   Discharge Instructions (AVS) (Printed 11/28/2023) Medication List at Discharge   amlodipine besylate 5 mg Oral DAILY  aspirin 81 mg Oral DAILY  atorvastatin calcium 20 mg Oral DAILY  cholecalciferol (vitamin D3) 1,000 Units Oral DAILY  docusate sodium 100 mg Take 1 to 2 capsules by mouth at bedtime as needed for constipation  miconazole nitrate 2 % Topical 2 TIMES A DAY  multivitamin 1 tablet Oral DAILY  psyllium husk 6 gram/6 gram Dissolve 1 rounded teaspoonful in 8 ounces of water and drink 2 times a day. Drink additional fluid after taking medication  tamsulosin HCl 0.4 mg Oral DAILY