Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Implantable defibrillator insertion, Insomnia, Insulin therapy, International normalised ratio increased, Low density lipoprotein normal
Clinical narrative: ID: Patient   Date of Admission: 11/12/2023    Date of Discharge: 11/14/2023    Primary Care Physician: MD   Issues to be Addressed in Follow-up: Resolution of Symptoms   Reason for Hospital Admission (Admitting Diagnosis):  COVID, hypoxia    HPI on admission (Pasion):  78 y/o M w/ known CAD, HTN, HL, a fib, hx of VT and has AICD, DM, obesity / OSAS, CKD st 1 - presents to the ER complaining of significant fatigue, inability to sleep for the past 2 days, loss of appetite and BS being all over the place. He also also complains of L lower back pain going for the past 2-3 weeks. He denies any fevers or chills, SOB or cough, CP, vomiting, abd pain or diarrhea.  In the ER, pt was found to hypoxiic w/ sats of 89% on RA. COVID +. CXR hypoventilated w/ a possible RLL infiltrate vs opacity or just atelectasis from hypoventilation. Has a mild AKI and mild hypokalemia as well. He has a very mild troponin elevated that dorwtrended on upon rpt check. He was given 1 lit of LR bolus and a total of 80 meq of po KCL.     Hospital Course/Significant Findings: Patient was admitted and treated with Remdesivir and Decadron. Patient's hypoxia improved and was ambulatory off O2 by day of discharge. Discharge on short course of Decadron.   Complications: None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? HX OF FALL   ? MILD COGNITIVE IMPAIRMENT OF UNKNOWN ETIOLOGY   ? PRESENCE OF AICD       Dual Chamber ICD Boston Scientific  Model:  Boston Scientific D533 RESONATE HF ICD Date of implant:  5/25/23 Patient is not pacemaker dependent Instruction for surgery:  1. Place magnet over device during surgery MRI conditional leads? yes   MRI conditional device? yes  Absolute contraindications for MRI present (implanted lead extenders, lead adaptors, abandoned, broken or epicardial leads)? no (See eConsult page "MRI for pacemaker pts" under Cardiology for info about MRI in patients with cardiac implanted electronic devices) Date last Updated:  6/1/2023   Additional notes: None         ? ATHEROSCLEROSIS OF AORTA       Chest x-ray 5/22/2023   ? VENTRICULAR TACHYCARDIA, MONOMORPHIC       Added automatically from request for surgery 1533945   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? ATRIAL FIBRILLATION, PAROXYSMAL        1/13/2023 Tan - Chart Update Seeing cardiology, started Pradaxa.       ? OBESITY, BMI 30-34.9, ADULT   ? SLEEP APNEA       EMBLETTA AMBULATORY SLEEP STUDY       9/3/16   Flow, SpO2, and pulse signal quality ADEQUATE   Diagnosis:    MILD Sleep Apnea (A+H = 13.5/hr)             O2 sat, mean = 94%; lowest = 80%; <90% = 11 minutes)             Apneas: n= 23;  70% =obstructive             Hypopneas = 69   ESS =  8 Estimated body mass index is 33.00   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA        CATH 5/25/2023: non obstructive coronary artery disease        ? CARDIOMYOPATHY, UNSPECIFIED        2/4/2022 - DOV Stable. No new symptom.   A/P: continue medications. And monitor   ? DM 2 W PROTEINURIA   ? VENTRICULAR TACHYCARDIA, NONSUSTAINED   ? DM 2 W CKD STAGE 1 (GFR >= 90 W OTHER KIDNEY DAMAGE MARKER)        7/17/2023 Tan - DOV  Notes stopped PM insulin dose of 45 U. AM only, No more low blood sugar.   A/P: Repeat A1c next month.    6/13/2023 - DOV  Past week cut down insulin and has not had low blood sugar. Noted to cardiology, low blood glucose (50s) frequently at night since hospitalization, was told to decrease his dinner NPH from 45 to 30 to start  We recently decreased glipizide 1 tab qAM (instead of 2 tabs qAM).    Lab Results Component Value Date   Hgb A1c % 8.0 (H) 05/17/2023   Hgb A1c % 7.7 (H) 01/31/2023   Hgb A1c % 8.3 (H) 02/04/2022   A/P: Has not had low blood sugar since decreasing insulin, on glipizide 1 tab. Will monitor and recheck A1c 2 months.     2/17/2023 - DOV  Here with wife. In ED 1/13/23, wife found him "out of it" , Paramedics called, BS 37-38. EKG with changes. Would like to discuss CGM. Checks BS four times daily. Same dose on insulin. Usually runs high per patient. Stable.   Lab Results Component Value Date   Hgb A1c % 8.0 (H) 05/17/2023 Forgot to bring home blood sugar log today. Will email.   A/P: A1c improved from prior but was sick with Shingles. Recheck 3 months. Order placed for CGM. Health ed referral placed.    2/4/2022 - DOV     Lab Results Component Value Date   Hgb A1c % 8.0 (H) 05/17/2023   A/P: continue medications. on insulin 60 U AM, 45 U PM. Recheck A1c.    8/19/2021 - DOV  history of occasionally low blood sugar with symptom. ~ 3 episodes, at altitude. Most recent this summer and 2 years ago. blood sugar home check four times daily.  Lab Results Component Value Date   Hgb A1c % 8.0 (H) 05/17/2023   A/P: Continue medications, on insulin 60 U AM, 45 U PM. Recheck A1c.         ? HYPERLIPIDEMIA        2/4/2022 - DOV  Lab Results Component Value Date   Cholesterol 111 12/06/2018   Triglyceride 167 12/06/2018   HDL 42 12/06/2018   Low density lipoprotein calculated 36 12/06/2018   A/P: Controlled on statin.       ? HTN        11/17/2022 - DOV Noted high in dentist 10/2022. Recheck at home and here been within normal limits.    BP Readings from Last 3 Encounters: 11/17/22 127/52 11/02/22 122/64 10/31/22 132/78   A/P: Controlled on current medications. Continue home monitor.         Resolved Hospital Problems No resolved problems to display.   Procedures: None   Consults:  None   Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code   Smoker: No.   Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).    Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Nov 24, 2023  1:50 PM  Office Visit (M.D.) ADULT AND FAMILY MEDICINE      Physical Exam on Day of Discharge: BP 162/93  | Pulse 68  | Temp 98.2 °F (36.8 °C)  | Resp 16  | Ht 5' 10"  | Wt 88.4 kg (194 lb 14.2 oz)  | SpO2 99%  | BMI 27.96 kg/m²    Intake/Output Summary (Last 24 hours) at 11/14/2023 1011 Last data filed at 11/14/2023 0700  Gross over last 24 hours Intake 1692.5 ml Output ? Net 1692.5 ml   General - A&Ox3. Resting comfortably in no acute distress Head - Normocephalic. Atraumatic Eyes - PERLA. EOMI Mouth - Oropharynx moist. No injection Neck - No lymphadenopathy. No JVD Lungs - Clear to auscultation. No wheezes, no crackles Heart - Regular rate and rhythm. No murmurs, no gallops Abdomen - Soft, nontender, nondistended, no guarding, no rebound Extremities - Good pulses bilaterally, no edema Musculoskeletal - Good strength bilaterally, no spinal tenderness Neuro - CN II-XII grossly intact, no sensory deficits Psych - Patient is of sound mind and proper affect   Selected Lab Results:  Recent Labs   11/14/23 0647 11/12/23 2300 WBC 6.4 4.5 HGB 13.5 13.3 HCT 39.7 38.7* PLT 117* 115* MCV 96 95      Recent Labs   11/14/23 0647 11/12/23 2300 NA 145 142 K 3.9 3.1* CO2 30 31 CL 106 102 BUN 21 19 CR 1.13 1.55* | 1.55* RBS 101 153 | 153 MG 1.2*  --       Recent Labs   11/14/23 0647 11/13/23 0555 AST 27 27 ALT 22 25 ALKP 69 91 TBILI 1.2 1.3* BILIDIRECT  --  0.3      Lab Results Component Value Date   PT INR 1.2 05/26/2023   PT INR 1.2 05/25/2023   PT INR 1.3 05/25/2023   PT INR 1.1 05/24/2023   PT INR 1.2 05/23/2023   PT INR 1.0 01/29/2016      Recent Labs   11/13/23 0205 11/12/23 2300 TROP 37* 40*      Fingerstick Blood Glucose (48 hours):   Device Integrated Values (if any)  GLUCOSE, BLOOD, GLUCOMETER Date/Time Value Ref Range Status 11/14/2023 0946 101 60 - 159 mg/dL Final 11/13/2023 2129 169 (H) 60 - 159 mg/dL Final 11/13/2023 1739 234 (H) 60 - 159 mg/dL Final 11/13/2023 1225 217 (H) 60 - 159 mg/dL Final 11/13/2023 0811 114 60 - 159 mg/dL Final   Time spent on discharge: > 35 minutes   Discussed with the patient. All questions fully answered.   DO   11/14/2023 10:11 AM  HBS      Note Details  Author (D.O.) File Time 11/14/2023 10:14 AM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine  Admit Date 11/12/2023  ED to Hosp-Admission (Discharged) on 11/12/2023  ED to Hosp-Admission (Discharged) on 11/12/2023   Detailed Report  Note shared with patient Hospital Problem List   HYPERLIPIDEMIA  HTN  DM 2 W CKD STAGE 1 (GFR >= 90 W OTHER KIDNEY DAMAGE MARKER)  DM 2 W PROTEINURIA  CARDIOMYOPATHY, UNSPECIFIED  CAD (CORONARY ARTERY DISEASE) WO ANGINA  VENTRICULAR TACHYCARDIA, MONOMORPHIC  ATHEROSCLEROSIS OF AORTA  MILD COGNITIVE IMPAIRMENT OF UNKNOWN ETIOLOGY  COVID-19 PNEUMONIA  SLEEP APNEA  OBESITY, BMI 30-34.9, ADULT  ACUTE HYPOXEMIC RESPIRATORY FAILURE  PRESENCE OF AICD  HX OF FALL  NONTRAUMATIC ACUTE KIDNEY INJURY  VENTRICULAR TACHYCARDIA, NONSUSTAINED  ATRIAL FIBRILLATION, PAROXYSMAL Care Timeline  11/13   Admitted from ED (Observation) 0459 11/14   Discharged 1726