Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Fall, Hypertension, Nephrolithiasis, Pyelonephritis acute, Type 2 diabetes mellitus
Clinical narrative: Date of Admission: 12/10/2023   Date of Discharge: 12/12/2023   Issues to be Addressed at Follow-up: Follow up with PCP for pending labs.    Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/11/2023  1:51 PM URINE CULTURE In process URINE   12/10/2023  2:41 AM BLOOD CULTURE 2 Preliminary BLOOD   12/10/2023  2:36 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE PYELONEPHRITIS   ? RENAL CALCULUS   ? UTI (URINARY TRACT INFECTION)   ? GRAM NEG BACTEREMIA   ? DM 2       8/29/2022 - DOV Will get a1c today, was fine last time.    ? HTN (HYPERTENSION)       11/29/2023 - DOV Did not take amlodipine, high today Low salt Will stop metoprolol for possible med related fall vs mechanical fall Pulse is in 60s   Will send numbers in 2 weeks with just amlodipine.   12/7/2023 - DOV  Better today, does not feel unstable at all  Continue amlodipine     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Per Dr. HPI: "  The patient is 67 F with hsitory of DM2, HTN, ED visits on 12/9 diagnosed with UTI. Returns because blood cultures positive. For the past two weeks has been having falls. +Orbital fracture on 11/29.  Denies back pain. Yesterday seen for weakness Dx with UTI. Also possible acute lacunar infarct. Patient refused MRI and started on ASA, Statin after d/w Neurology.  Outpatient MRI ordered. She denies fever tonight or chills. Feel a little better Daughter at bedside translating No sepsis on ED visit with normal lactate and Wbc.  2/2 blood cultures +GNR "   Patient was cultured blood and urine during the course of her stay antibiotic structured program recommended if patient stable transition from IV or ertapenem to Cipro for total of 14 days.  Patient remained hemodynamically stable remained afebrile for greater than 36 hours was ambulatory tolerating diet good bowel bladder function.   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Acute pyelonephritis Incidental COVID-positive status post RDV treatment 3 days home isolation till 12/20/2023   Complications: none   Consults:  None Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author (M.D.) File Time 12/12/2023  1:30 PM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023   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   DM 2  HTN (HYPERTENSION)  ACUTE PYELONEPHRITIS  UTI (URINARY TRACT INFECTION)  GRAM NEG BACTEREMIA  RENAL CALCULUS Care Timeline  12/10   Admitted from ED (Observation) 0402 12/11   Admitted 1258 12/12   Discharged 1707  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 12/12/2023) Medication List at Discharge   amlodipine besylate 5 mg Oral DAILY  aspirin 81 mg Oral DAILY  atorvastatin calcium 20 mg Oral DAILY, to reduce risk of heart attacks and strokes  baclofen 20 mg Oral 3 TIMES A DAY AS NEEDED  benazepril HCl 20 mg Oral EVERY MORNING  cholecalciferol (vitamin D3) 1,000 Units Oral DAILY  ciprofloxacin HCl 500 mg Oral EVERY 12 HOURS  famotidine 40 mg Oral 2 TIMES A DAY  fluoxetine HCl 40 mg Oral DAILY  gabapentin 600 mg Oral 3 TIMES A DAY  Lactobacil 2/Bifido 1/S.thermo 112.5 billion cell 2 capsules Oral DAILY  lancets 33 gauge Test once daily  metformin HCl 500 mg Oral EVERY EVENING WITH A MEAL  triamcinolone acetonide 0.1 % Apply to affected area(s) 2 times a day as needed for rash . Stop when rash is gone. Do not use on face, neck or skin folds