Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Iron deficiency anaemia, Malnutrition, Mean cell volume normal, Oesophagogastroduodenoscopy normal, Platelet count normal
Clinical narrative: Date of Admission: 1/6/2024   Date of Discharge: 1/14/2024   Issues to be Addressed at Follow-up: Follow up on COPD treatment Follow up on Sodium Levels   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 12/15/2023 to 1/15/2024.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) HYPONATREMIA   ? SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE SECRETION   ? SEVERE PROTEIN CALORIE MALNUTRITION   ? ATRIAL FIBRILLATION W RAPID VENTRICULAR RESPONSE       10/16/2023   Triggered by pneumonia Declines typical anticoagulation - will take aspirin and plavix - she is aware of this and is of sound mind    11/9/2023   Will discuss in person - she does not want to start apixiban    11/16/2023   Not taking apixiban or diltiazem - t hinks her heart is ok and was triggered by pneumonia   Will continue to address in future visits   She will stop aspirin and plavix and start apixiban now.   ? PREDIABETES   ? OBSTRUCTIVE SLEEP APNEA       Date: 7/10/2019  Study Type: WatchPAT  pAHI: 18.3  BMI: 23.78   ESS: 11  Min SpO2: 78% SpO2<90%: 131.8 minutes Moderate Sleep Apnea. - couldn't tolerate any cpap mask   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)       6/27/19 EGD with C0M1 Barrett's esophagus.   Barrett's esophagus (a precancerous change in the esophagus that can occur in patients with long-standing acid reflux disease). This should be re-assessed in 3-5 years.   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA       Stent to cirumflex in 2003   Consider starting beta blocker but has many other priorities and has COPD/smoking history   ? COPD STAGE 2 MODERATE (FEV1 50-79%)       12/28/2023  hospitalization for COPD exacerbation 2/2 covid, not pneumonia No hypoxemia on d/c, does not qualify for o2 at the moment Will refer to medical facility for closer follow up given multiple touch points in our medical system    ? IRON DEFICIENCY ANEMIA       EGD/colonscopy Recommendations:   - No findings on today's examination to explain patient's iron deficiency anemia - Await pathology, treat for H. Pylori if positive - Continue oral iron supplementation and trend CBC/iron/TIBC/ferritin - If biopsies negative for cause and anemia fails to respond to oral iron supplementation, can consider small bowel evaluation. Follow-up with PCP and patient's primary gastroenterologist, Dr. as needed.   ? TOBACCO SMOKER   ? HTN (HYPERTENSION)       6/19/2023- Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Well controlled with no side effects from medications, continue plan.       Resolved Hospital Problems   Diagnosis Date Resolved ? HYPOGLYCEMIA 01/14/2024     Discharge Disposition:  Shelter   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: From Dr. 1/9 D/C summary:  Hospital Course and Significant Findings: 67 year old with a PMHx of homelessness,  COPD, not on home 02( declined in past ), Active smoker , chr hyponatremia , GERD, PVD, OSA , HTN, CAD,  Afib, who states she has not started Pradaxa, has felt tired and sleeping most of the day. Fatigue started 3 days ago. No fevers or chills reported . Last ate food three days ago. Notes she had COVID 6 weeks ago. No new symptoms reported. No cough, no shortness of breath. CXR: Emphysema. No consolidation Found to have Na of 117,  initiated on Sodium chloride tabs 1gm and small dose Lasix. Sodium level gradually improved to 129 in 3 days. Patient is requiring 2 L supplemental oxygen. She is still testing positive for COVID. No evidence of new infection, no fever or URI symptoms , dose have chronic cough . Discussed with ID on call, her CT value is 1/6 is 33.3 ( initial was 30 ) . While in hospital COVID isolation per protocol continued. She will be discharged back to shelter on supplemental 02. Shelter requested another COVID test on 1/9 before transfer  , which is again positive . Per ID not sure if new exposure. ID on call recommend total 10 days of isolation from 1/6 to 1/16. Per ID Dr" do not check more COVID tests " .   Sodium chloride 1gm TID for 3 more days and fluid restriction.  Repeat CHEM-7 outpatient within 1 week is needed.    Stopped requiring oxygen by HD7.  Social work reached out to shelter yesterday upon my request to query if they would accept home antigen test negative (as COVID PCR test can persist for several months).  We do not do antigen testing in the hospital but patient was able to purchase a test from the pharmacy and perform it in front of the nurse who verified the results (also under photo tab).     PROGRESS NOTE    Hospital Day(s): 8   Subjective: Pt feels well.  Was able to do a home antigen test for COVID that was negative today and was happy the shelter was going to be able to take her back.    Objective: Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 01/14/24 1332 ? ? 84 114/66 ? ? ? 01/14/24 1012 ? ? 88 ? 16 97 % RA 01/14/24 0847 98 °F (36.7 °C) Oral 74 118/78 16 94 % RA 01/13/24 2356 98 °F (36.7 °C) Oral 73 129/81 18 93 % RA 01/13/24 2111 ? ? 79 121/76 ? ? ? 01/13/24 1745 ? ? 80 120/91 18 ? RA 01/13/24 1643 97.3 °F (36.3 °C) Oral ? ? 16 ? RA     Intake/Output Summary (Last 24 hours) at 1/14/2024 1618 Last data filed at 1/14/2024 0900  Gross over last 24 hours Intake 780 ml Output ? Net 780 ml       Physical Exam: General appearance - alert, well appearing, and in no distress Chest - clear to auscultation, no wheezes, rales or rhonchi Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs Abdomen - soft, nontender, nondistended, no masses or organomegaly Extremities - no clubbing, cyanosis or edema     Selected Results:  Recent Labs Recent Results (from the past 24 hour(s)) CBC NO DIFFERENTIAL   Collection Time: 01/14/24  8:38 AM Result Value Ref Range   WBC COUNT 8.1 3.7 - 11.1 K/uL   Red blood cells count 4.05 3.60 - 5.70 M/uL   Hgb 12.5 11.5 - 15.0 g/dL   Hematocrit 37.3 34.0 - 46.0 %   MCV 92 80 - 100 fL   RDW, RBC 13.6 12.0 - 16.5 %   Platelets count 348 140 - 400 K/uL   RBC's, nucleated 0 <=0 /100WC CHEM 7 (NA, K, CL, CO2, BUN, GLUC, CR)   Collection Time: 01/14/24  8:38 AM Result Value Ref Range   Sodium 130 (L) 135 - 145 mEq/L   Potassium 4.7 3.5 - 5.3 mEq/L   Chloride 93 (L) 100 - 111 mEq/L   CO2 31 24 - 33 mEq/L   Anion gap, ser/plas 6 5 - 16 mEq/L   BUN 4 (L) 7 - 27 mg/dL   GLUCOSE, RANDOM 90 60 - 159 mg/dL   Creatinine 0.43 <=1.11 mg/dL SARS-COV-2, (COVID-19) ANTIGEN, QUALITATIVE, RAPID IMMUNOASSAY NEGATIVE   Collection Time: 01/14/24 12:43 PM Result Value Ref Range   SARS-COV-2 (COVID-19) ANTIGEN, QUALITATIVE, RAPID IA COVID NOT DETECTED       Lab Results Component Value Date/Time   CORONAVIRUS COVID DETECTED (A) 01/09/2024 05:27 PM   CORONAVIRUS COVID DETECTED (A) 01/06/2024 07:10 PM   CORONAVIRUS COVID DETECTED (A) 12/18/2023 06:40 PM   CORONAVIRUS COVID DETECTED (A) 12/08/2023 06:30 AM   CORONAVIRUS COVID NOT DETECTED 10/08/2023 09:44 AM         Assessment and Plan: Patient Active Hospital Problem List:  HYPONATREMIA (7/8/2021) SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE SECRETION (1/9/2024)   Assessment:Improved when pt resumed salt tabs.    Plan: encouraged increased PO intake of salt and fluid restriction.  TOBACCO SMOKER (3/25/2019)   Assessment: noted   Plan: encourage cessation  COPD STAGE 2 MODERATE (FEV1 50-79%) (3/25/2019)   Assessment: noted   Plan: discharged on home regiment, may benefit from COPD care management.   IRON DEFICIENCY ANEMIA (3/25/2019)   Assessment: noted   Plan: MVI with minerals  CAD (CORONARY ARTERY DISEASE) WO ANGINA (6/5/2019)   Assessment: noted   Plan: The current medical regimen is effective;  continue present plan and medications.   HTN (HYPERTENSION) (4/6/2015)   Assessment: noted, controlled in hospital   Plan: The current medical regimen is effective;  continue present plan and medications.   GERD (GASTROESOPHAGEAL REFLUX DISEASE) (7/1/2019)   Assessment: noted   Plan: The current medical regimen is effective;  continue present plan and medications.   OBSTRUCTIVE SLEEP APNEA (7/11/2019)   Assessment: noted   Plan: CPAP recommended  PREDIABETES (5/20/2020)   Assessment: noted   Plan: monitor glucose with am labs  ATRIAL FIBRILLATION W RAPID VENTRICULAR RESPONSE (10/8/2023)   Assessment: noted   Plan: pradaxa and diltiazem  SEVERE PROTEIN CALORIE MALNUTRITION (1/8/2024)   Assessment:   Lab Results Component Value Date   Albumin 4.5 12/08/2023     Plan: nutritional support     Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Hyponatremia, Hypoglycemia     Complications: none   Consults:  None Smoker: Yes - Reason Medication or Counseling not ordered: Patient declined follow-up smoking cessation counseling   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code      Note Details  Author (M.D.) File Time 1/14/2024  4:26 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Internal Medicine Hospital Acct #  Admit Date 1/6/2024  ED to Hosp-Admission (Discharged) on 1/6/2024  ED to Hosp-Admission (Discharged) on 1/6/2024   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   COPD STAGE 2 MODERATE (FEV1 50-79%)  CAD (CORONARY ARTERY DISEASE) WO ANGINA  HTN (HYPERTENSION)  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  OBSTRUCTIVE SLEEP APNEA  ATRIAL FIBRILLATION W RAPID VENTRICULAR RESPONSE  SEVERE PROTEIN CALORIE MALNUTRITION  SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE SECRETION  HYPONATREMIA  TOBACCO SMOKER  IRON DEFICIENCY ANEMIA  PREDIABETES  HYPOGLYCEMIA Resolved Care Timeline  01/06   Admitted from ED (Observation) 2237 01/14   Discharged 1633  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 1/14/2024)   Discharge Orders BICARBONATE BUN CBC + DIFF (AT REG LAB). CHLORIDE CREATININE W GFR, CALCULATED GLUCOSE POTASSIUM SODIUM Medication List at Discharge   albuterol sulfate 90 mcg/actuation Inhale 1 to 2 puffs by mouth every 4 to 6 hours as needed. Note: different manufacturer.  ascorbic acid 500 mg Oral DAILY  aspirin 81 mg Oral DAILY  atorvastatin calcium 20 mg Oral EVERY EVENING  budesonide/formoterol fumarate 160-4.5 mcg/actuation Inhale 2 puffs by mouth 2 times a day as directed (Note: This replace Symbicort)  calcium carbonate/vitamin D3 600 mg-10 mcg (400 unit) 1 tablet Oral 2 TIMES A DAY, with food  COVID-19 antigen test Use as directed on package  dabigatran etexilate mesylate 150 mg Oral 2 TIMES A DAY  diltiazem HCl 30 mg Oral 3 TIMES A DAY  ferrous sulfate 325 mg Oral DAILY, or as directed  gabapentin 600 mg Oral 3 TIMES A DAY, Part of a taper since starting venlafaxine. Next refill should be 300 mg tid  guaifenesin 600 mg Oral EVERY 12 HOURS  lisinopril 20 mg Oral DAILY  magnesium oxide 500 mg Oral DAILY  montelukast sodium 10 mg Oral EVERY BEDTIME  nitroglycerin 400 mcg/spray 1 Spray Translingual EVERY 5 MINUTES AS NEEDED  omeprazole 40 mg Oral DAILY  sodium chloride 1 g Oral 3 TIMES A DAY  tiotropium bromide 2.5 mcg/actuation 2 Puffs Inhalation DAILY