Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Dyspnoea, Glomerular filtration rate decreased, Hypertension, Lactic acidosis
Clinical narrative: Physician Specialty:  Hospital Medicine Discharge Summary     Signed  Signed    Date of Admission: 10/10/2023   Date of Discharge: 10/12/2023   Issues to be Addressed at Follow-up: COVID-19 infection Superimposed bacterial pneumonia Severe sepsis with acute organ dysfunction   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/10/2023 10:35 AM BLOOD CULTURE 2 Preliminary BLOOD   10/10/2023 10:02 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? DM 2 W CKD STAGE 3B (GFR 30-44) W HTN   ? HTN (HYPERTENSION)   ? DM 2     Resolved Hospital Problems   Diagnosis Date Resolved ? SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION 10/12/2023 ? LACTIC ACIDOSIS, UNSPECIFIED 10/12/2023     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Severe sepsis with acute organ dysfunction likely due to possible superimposed bacterial pneumonia COVID-19 infection  This 80-year-old gentleman with a known history of type 2 diabetes mellitus, benign essential hypertension, chronic and disease stage III presented to emergency department with difficulty breathing, fever or chills, found to have COVID-19 infection with bilateral lower lobes infiltrate, remained on room air during this hospital course, given the presence of severe sepsis with lactic acidosis and concern for superimposed pneumonia it was deemed appropriate for patient to be placed on empiric antibiotics with ceftriaxone and doxycycline.  Patient also received remdesivir, has not been provided with any steroids in the absence of significant hypoxemia.   Subsequently patient was noted to be significantly improved within 48 hours stay in the hospital he was able to ambulate within the room independently without needing any oxygen, at which point it was deemed patient to be discharged.   Patient has been provided with further 5 days of doxycycline, recommended for appropriate over-the-counter mucolytic's as well as informed about the incentive spirometer.   Patient's blood pressure remained stable during this hospital course, antihypertensives were resumed prior to discharge, blood pressure remained stable.     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Bibasilar pneumonia with COVID-19 infection Severe sepsis with acute organ dysfunction-resolved   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. 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 10/12/2023  1:28 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Admit Date 10/10/2023  ED to Hosp-Admission (Discharged) on 10/10/2023  ED to Hosp-Admission (Discharged) on 10/10/2023   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   COVID-19 PNEUMONIA  LACTIC ACIDOSIS, UNSPECIFIED Resolved  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION Resolved  DM 2  HTN (HYPERTENSION)  DM 2 W CKD STAGE 3B (GFR 30-44) W HTN Care Timeline  10/10   Admitted from ED (Observation) 2000 10/12   Discharged 1218  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/12/2023) Medication List at Discharge   amlodipine besylate 2.5 mg Oral DAILY  blood sugar diagnostic Use as directed for blood glucose monitoring 3 times per day  blood-glucose meter Use as directed to test blood sugar  doxycycline monohydrate 100 mg Oral EVERY 12 HOURS  insulin glargine,hum.rec.anlog 100 unit/mL INJECT 27 UNITS UNDER THE SKIN EVERY EVENING AND AS DIRECTED TO CONTROL BLOOD SUGAR FOR YOUR DIABETES  insulin regular, human 100 unit/mL Inject 7 units subcutaneously before each meal. Titrate by 2 units every 3 to 4 days until pre meal blood sugars are below 150. CALL PROVIDER IF FBS IS UNDER 70 OR USING 30 UNITS AND FBS IS OVER 150  loratadine 10 mg Oral DAILY AS NEEDED  losartan/hydrochlorothiazide 100-25 mg 1 tablet Oral EVERY MORNING