Age: 63.0
Sex: M
Vaccine: COVID19
Symptoms: Troponin normal, Type 2 diabetes mellitus, Vascular device user
Clinical narrative: Date of Admission: 10/17/2023   Date of Discharge: 10/23/2023   Issues to be Addressed at Follow-up: Admission Weight: Weight: 78.5 kg (173 lb) (10/17/23 1826)  Baseline Creatinine:  Around point 6   Discharge Weight: Weight: 64.8 kg (142 lb 14.4 oz) (10/23/23 0539) Discharge Creatinine:   Lab Results Component Value Date   Creatinine 0.53 10/23/2023       Estimated Target Weight (if known): estimate 138 to 140lbs   Discharge Oxygen Saturation:     10/23/2023 O2 Sat % 96 O2 (LPM) -    Last EF:   LV EJECTION FRACTION Date Value Ref Range Status 09/13/2023 35 % Final    LEFT VENTRICULAR EJECTION FRACTION Date Value Ref Range Status 06/25/2022 35 % Final    Volume Status/Diuretic Plan until follow-up: Patient needs additional diuresis. Patient is being discharged on the CHF flexible diuretic plan.   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 9/23/2023 to 10/24/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) CHRONIC RESPIRATORY FAILURE   ? COVID-19 DISEASE   ? HYDROPNEUMOTHORAX       Chronic right pleural effusion Right pneumothorax post right thoracentesis 9/12/2023. Trapped right lung.   ? HYPOMAGNESEMIA   ? HEART FAILURE W REDUCED LVEF 31-40%, UNSPECIFIED ACUITY         10/23/2023 MD - update Hospital follow up  Was admitted again for HF with trapped lung, required thoracentesis He is back at his baseline today, still feels overall weak, mild SOB but at baseline Weight today is 163 at home He reports taking "most of my medications" but not taking all of them.  Does not like taking all his medications every day.   He does not know their names, and has no list with him to confirm them.   I have tried multiple ways to help him with adherence I have talked with his daughter I have had health educators and diabetic pharmacist talk to him Patient refuses to see cardiology in follow-up Refuses pulmonary specialty appointment Refuses diabetes control with medications   ? ISCHEMIC CARDIOMYOPATHY         5/12/2023 OV Not taking all of his medications regularly for the past few months.   He gives many different reasons for this, including " I did not know I had refills", " I needed to take a break", "I feel fine, so I do not think I need to take them all the time" Long conversation about importance of ongoing medical management of his significant cardiac issues.     Ant STEMI 7/9/2021 ECHO Severely reduced LV systolic function with an estimated ejection fraction of 25-30%.  The entire apex, anteroseptal, inferoseptal walls are akinetic.  Mildly abnormal diastolic function.  The right ventricle is normal . Right ventricular function low normal . No significant valvular abnormalities. No prior echo for comparison.     Function: no limitations, rides bike daily, no SOB or CP   ? CAD WO ANGINA, PRESENCE OF STENT       11/11/2022 DOV Patient has not followed up with cardiology, nor did he follow through with cardiac therapy which was recommended.   He ran out of all of his medicines 3 to 4 months ago-- when asked why he did not just pick up more, he became quiet and did not answer me. He did not say that his co-pays were prohibitively high for him   June 2021: Rt dom, LM: 0%, LAD: 100% occ prox s/p (3X28 Synergy DES), 40% diffuse mid distal LAD (prob late presentation ant MI), CIRC: 60% distal diffuse (SM caliber), 30% mid CIRC dz, RCA: 40% mid, 85% dRCA at bifurcation.LV 27mmHG .distal LCX (small caliber) which will be treated medically. Severe disease of the distal RCA at the bifurcation which can be considered for PCI later on based on clinical need.   Plavix till 6/30/2022 and ASA lifelong   LEFT VENTRICULAR EJECTION FRACTION Date Value Ref Range Status 06/25/2022 35 % Final   Referred to MF   ? DM 2 W HYPERLIPIDEMIA       5/12/2023: Patient inconsistently taking medications.  Working with APM. Recently " taking a break" from his medications which he feels are excessive    Lab Results Component Value Date   Hgb A1c % 8.7 (H) 03/22/2023   Discussed the importance of him remaining adherent to all of the prescribed medications to prevent complications Needs Q 3 mo A1C dscussed role of APM for more close contact and medication adjustments--printed out information and phone number to his APM   Oct 2021 Pt stopped all his medications 3 weeks ago bc he was feeling weak and short of breath.  He has been off all for 3 weeks A few days ago he decided to resume only his jardiance and lasix, but still wary of taking any others. Not measuring blood sugar--says when he feels weak sometimes he gets sweaty and nauseated. He has not had an episode like this for at least a week however. Feels well today.   Treatment: metformin 1g bid, glipizide 10 bid, Jardiance recently initiated Currently, has been off these medications but recently resumed Jardiance a few days ago.   Discussed long-term management of diabetes and the importance of good diabetic control to prevent future vascular events. He agrees to resume his medications and start checking blood sugar levels Will need close follow-up and monitoring   Checks blood sugar in the mornings, running 170-1 80 No hypoglycemia known, but occasionally feels fatigued and shaky " my blood sugar is too low" prompting him to eat a bunch of mango.  He does not test his blood sugar when he feels this way. Encouraged testing when he feels the symptoms to avoid overreacting with sweet foods Follow up with PharmD next week as scheduled. Retinal exam today   July 2021: Not taking glipizide Reiterated all medications, dietary changes, secondary prevention A1C in 3 mo    Lab Results Component Value Date   Hgb A1c % 8.7 (H) 03/22/2023   Due for: immunizations, discussed --he wants to wait on them  Discussed diet/exercise/healthy weight goals/implications of uncontrolled DM in the longterm         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: 65yo man with hx of CAD, ischemic CM, HFrEF with EF 35% by TTE Sept 2023, chronic right pleural effusion, hx of CVA, DM2, hx of medication non-adherence. He was admitted in Aug and Sept for CHF exacerbation. In Sept he had thoracentesis but had hydropneumothorax afterward and he was felt to have trapped lung. At discharge econsult was done but thoracic surgery was unable to contact the patient. He underwent 2.5L thoracentesis in the ED 10/6 and was Covid 19 positive. He went home and took 4 doses of paxlovid. He was in the ED 10/9 and 10/17 with shortness of breath and again had hydropneumothorax. At follow up 10/10 he told his PCP he was only taking his lasix and no other medications and refused to believe he had covid. At baseline he lives with a room mate and uses home o2. He endorsed not taking lasix for 3 days but not clear why.    In the ED 10/18 he was not hypoxemic but had increased work of breathing. He had no rise in troponins and BNP 1244. Xray showed hydropneumothorax again. He was admitted and started on lasix. He continued to diurese well with improving hypoxemia. With marginal BP, aldactone and lisinopril were not given. Coreg was changed to low dose metoprolol.       ISCHEMIC CARDIOMYOPATHY (6/30/2021) and  HEART FAILURE W REDUCED LVEF 31-40%, UNSPECIFIED ACUITY (7/16/2021) and CHRONIC RESPIRATORY FAILURE (10/18/2023)   Assessment: frequent exacerbations. Non adherent to recommended therapies and not watching weight at home. Prior to this admission he states he only takes lasix, aspirin, and sometimes eliquis. During this admission he diuresed down to 142 lbs on IV lasix. He remains with 1+ pitting leg edema and ongoing hydropneumothorax   Plan:             Prescribed aldactone and lisinopril but not taking. Stop with low BP            Prescribed empagliflozin but not taking. Asked him to resume at discharge            Prescribed coreg but not taking. Try changing to low dose metoprolol XL for less BP lowering effect             Prescribed atorvastatin but not taking            IV lasix for diuresis            I do not feel he should be given entresto with risk of medication nonadherence and lack of lab follow up. At risk of serious complications including hypotension and hyperkalemia.             Offered CHF education in foreign language            Asked him to buy a scale at home to track his weights            Educated him on doubling lasix if he gains weight            Will need follow up in a week and hopefully closely            I am not confident he will participate with CHF clinic   HYDROPNEUMOTHORAX (9/14/2023)   Assessment: again seen on imaging. Present since attempt at chest tube placement in Sept.  Per Dr. assessment 9/15/23 Pattern of chronic effusion with postprocedure pneumothorax is highly suggestive of trapped lung. With a trapped lung, the patient's lung will not fully expand due to scarring around the lung preventing reexpansion. The only long term solution to this would be thoracic surgery for decortication. Generally thoracic surgery is reluctant to do decortication in patient's who have heart failure and are on anticoagulants.  If the trapped lung is a chronic problem for the patient causing shortness of breath that is not due to the CHF, then as an outpatient, the patient could be referred to thoracic surgery for consideration of decortication.   Plan: no plans for decortication at this time            Seems likely when he can keep CHF compensated he is able to breathe adequately. With medication non-adherence and uncontrolled diabetes I do not feel decortication is ideal            I sent a message to Dr. to notify him of this admission   COVID-19 DISEASE (10/7/2023)   Assessment: Covid positive 10/7. He did not take the paxlovid given to him at that time. Doubt resp failure due to covid pneumonia. Negative antigen test at bedside 10/20   Plan: steroids not given            Remdesivir given for a few doses and then stopped.            No further covid isolation needed   HYPOMAGNESEMIA (9/14/2023)   Assessment: noted   Plan: replace as needed   DM 2 W HYPERLIPIDEMIA (11/30/2020)   Assessment: Non compliant with glipizide and metformin at home A1c 11   Plan: empagliflozon            Glipizide 5mg bid            Can resume metformin at discharge            Diabetes education given in foreign language. Strongly urged him to take medications and check his blood sugars   CAD WO ANGINA, PRESENCE OF STENT (6/30/2021)   Assessment: stable   Plan: continue asa/eliquis            Statin            BB .  Primary Procedures:  none   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  CHF exacerbation   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   -----------------------------------------   HBS progress note:   Subjective: foreign language interpreter used. Feels like ready for home. Tired walking but better. Not using O2. Again described each of his meds and what they do and why he should take them.    Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 10/23/23 1600 98.5 °F (36.9 °C) Oral 71 110/75 18 96 % RA 10/23/23 0830 98.7 °F (37.1 °C) Oral 74 102/77 17 94 % RA 10/23/23 0539 98.7 °F (37.1 °C) Oral 75 92/68 18 93 % RA 10/23/23 0010 98.8 °F (37.1 °C) Oral 76 94/70 18 95 % RA 10/22/23 2225 ? ? ? ? ? 92 % RA   Patient Vitals for the past 72 hrs:    Weight 10/23/23 0539 64.8 kg (142 lb 14.4 oz) 10/22/23 0527 66.3 kg (146 lb 1.6 oz)   Physical Exam General appearance - alert, well appearing, and in no distress Mental Status - alert, oriented x 3 Eyes - extraocular eye movements intact, sclera anicteric Nose - normal and patent Throat - normal Chest - decreased breath sounds noted right chest throughout, left chest basilar crackles Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs Abdomen - soft, nontender, nondistended, no masses or organomegaly Neurological - motor and sensory grossly normal bilaterally Extremities - pedal edema 1+ in thighs and legs Skin - warm and dry     Note Details  Author (D.O.) File Time 10/23/2023 10:21 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Admit Date 10/17/2023  ED to Hosp-Admission (Discharged) on 10/17/2023  ED to Hosp-Admission (Discharged) on 10/17/2023   Routing History   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 W HYPERLIPIDEMIA  CAD WO ANGINA, PRESENCE OF STENT  ISCHEMIC CARDIOMYOPATHY  HEART FAILURE W REDUCED LVEF 31-40%, UNSPECIFIED ACUITY  CHRONIC RESPIRATORY FAILURE  HYDROPNEUMOTHORAX  COVID-19 DISEASE  HYPOMAGNESEMIA Care Timeline  10/18   Admitted from ED 1617 10/23   Discharged 1806  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/23/2023)   Discharge Orders B-TYPE NATRIURETIC PEPTIDE (BNP) BICARBONATE BUN CHLORIDE CREATININE W GFR, CALCULATED GLUCOSE POTASSIUM SODIUM Medication List at Discharge   apixaban 5 mg Oral 2 TIMES A DAY  aspirin 81 mg Oral DAILY  atorvastatin calcium 40 mg Take 1 tablet by mouth daily to prevent heart attacks and strokes.   blood sugar diagnostic 1 Strip Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  blood-glucose control, normal Use as directed with blood glucose meter  blood-glucose meter Use as directed to test blood sugar  empagliflozin 25 mg Take 1 tablet by mouth daily for diabetes.   furosemide 40 mg Take 1 tablet by mouth every morning . If weight gain of 2 or more pounds in 1 day, or 4 or more pounds in 4 days, take 2 tablets every morning for 3 days. If weight back to baseline, resume previous dose. If not, call your provider  glipizide 10 mg Take 1 tablet by mouth 2 times a day 30 minutes before breakfast and dinner for diabetes.   lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  metformin HCl 1,000 mg Take 1 tablet by mouth 2 times a day with meals for diabetes.   metoprolol succinate 12.5 mg Oral DAILY