Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Hypotension, Hypovolaemia, Hypoxia, Implantable defibrillator insertion, International normalised ratio
Clinical narrative: Date of Admission: 11/24/2023   Date of Discharge: 12/3/2023   Issues to be Addressed at Follow-up:   Monitor for covid complications.    Followup with podiatry for heel wounds . appt on 12/6/23     Pending Study Results at Discharge:      Unresulted Lab Orders    No orders found from 11/2/2023 to 12/3/2023.         Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? HTN (HYPERTENSION)       2/14/2023  lisinopril, coreg, hydralazine, furosemide    [] recheck cre and pot due to furosemide     BP Readings from Last 1 Encounters: 02/14/23 126/66    Lab Results Component Value Date   Creatinine 1.01 02/04/2023    Lab Results Component Value Date   Sodium 140 02/04/2023    Lab Results Component Value Date   Potassium 4.6 02/04/2023       ? UTI (URINARY TRACT INFECTION)   ? PRESENCE OF AICD       2/14/2023: Chronic established diagnosis. Briefly reviewed.    Reason For Device: ICM Single Chamber PM Medtronic    Model:/Date of implant:  Pt has a Single chamber AICD Medtronic Evera XT VR DVBB1D4 implanted 10/23/2014. RV lead is Medtronic 6947M Sprint Quattro Secure implanted 10/23/2014.     Patient is pacemaker dependent If surgery site is below the diaphragm no magnet is needed. MRI conditional leads? no   MRI conditional device? no  (See eConsult page "MRI for pacemaker pts" under Cardiology for info about MRI in patients with cardiac implanted electronic devices) Absolute contraindications for MRI present (implanted lead extenders, lead adaptors, abandoned, broken or epicardial leads)  Magnet Rate:The magnet rates for different modes vary according to the available battery life Date last Updated: 08/10/2022           ? LEUKOCYTOSIS   ? ISCHEMIC CARDIOMYOPATHY       2/14/2023  Chronic established diagnosis. Briefly reviewed.  No changes in management.  furosemide, hydralazine, carvedilol, lisinopril  Mitchel    akinetic septum      ? DM 2 W CKD STAGE 2 (GFR 60-89 W OTHER KIDNEY DAMAGE MARKER) W HTN       2/14/2023  Chronic established diagnosis. Briefly reviewed.    Lab Results Component Value Date   Creatinine 1.01 02/04/2023    Lab Results Component Value Date   Potassium 4.6 02/04/2023    Lab Results Component Value Date   Sodium 140 02/04/2023    BP Readings from Last 1 Encounters: 02/14/23 126/66         ? ANTICOAGULATION MONITORING, INR 2.0-3.0       Start date: 6/19/23  Indication: Atrial fibrillation. INR goal range: 2.0-3.0.  End date: Life-long (provider to asses risk vs benefit periodically). Napa-Solano Anticoagulation Service. Provider line.  Patient line. Fax: Pool name:. Hours: Mon-Fri  8:30am-4:30pm.     ? DM 2       2/14/2023: Chronic established diagnosis. Briefly reviewed. insulin NPH    Lab Results Component Value Date   Hgb A1c % 6.2 (H) 10/28/2022 []  due for DM retinal screening, will have MA schedule  [] recheck A1c    ? HX OF STROKE       2/14/2023 Chronic established diagnosis. Briefly reviewed.  No changes in management.      ? SLEEP APNEA       2/14/2023 Chronic established diagnosis. Briefly reviewed.  No changes in management.  was using CPAP at home, but is broken.   [] referred to sleep department  AHI: 15.9     ? ANEMIA       2/14/2023: Chronic established diagnosis. Briefly reviewed plan today likely ACD with slight iron def.  -- recommend(ed) to take iron rich MVI  q day    [] recheck h/h and iron in 3 months     Lab Results Component Value Date   WBC COUNT 8.2 02/04/2023   Hgb 9.7 (L) 02/04/2023   Hematocrit 32.5 (L) 02/04/2023   Platelets count 236 02/04/2023         ? TOBACCO SMOKER       2/14/2023  A: continues at 3 cigarettes a day   P:  -- urged to quit.     ? COVID-19 DISEASE   ? PRESSURE ULCER OF RIGHT HEEL STAGE 2 (PARTIAL THICKNESS SKIN LOSS)   ? PARAPLEGIA       2/14/2023: Chronic established diagnosis. Briefly reviewed.   -- has electric chair   ? HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Board and Care   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Please see full H&P for details.   Briefly, this is a 68-year-old female with stroke and paraplegia, CKD, HFrEF (EF 20-25%), atrial fibrillation and aortic thrombus on warfarin, HTN, DM2, OSA and tobacco use , recent ED visit 11/22/23 showing AKI and incidental COVID-19 presented with generalized pain and weakness from SNF rehab.          PRIMARY PROBLEM(S):   COVID-19 Disease:  Had mild hypoxia on admission.  s/p course of remdesivir.   On RA now.  Covid precautions ended 12/1/23.  She has also been on decadron with projected end date of 12/3/23 but she is now off oxygen thus won't continue.    Previously she  was at SNF and doesn't want to go back.   Plan for dc to board and care.   - B&C placement     Acute on chronic kidney injury - Cr bumped to 2.77 on admission.   Likely due to hypotension and hypovolemia on admission in setting of covid.   .   Creatinine improved.  Bumex and losartan has been on hold, but now restarted.  - monitor as outpatient      SECONDARY PROBLEM(S):     UTI -  s/p course of Ceftriaxone earlier in admission.  Culture came back with candida.      Ischemic Cardiomyopathy, HFrEF (20-25%) Hx of  AICD:   -  Continue coreg - cont  bumex.      Atrial Fibrillation -  Continue amiodarone, coreg -  Warfarin protocol   Hypertension: on coreg and losartan      DM 2:  - Continue ISS prn while here.   Resume jardiance on discharge     Pressure Ulcers:  Due to paraplegia, she has bilateral heel ulcers and coccyx/buttock ulcers.  Was followed by wound nurse this admission.  - continue wound care per Home Health as recommended by wound care RN -  Followup with podiatry for heel wounds . appt on 12/6/23     Hx of Stroke  Paraplegia  - noted from prior stroke.   Patient does not want to go back to SNF rehab and social work was consulted regarding discharge planning.  Plan for B&C placement   NONCOMPLIANCE  - of note , pt was found with a vape multiple times in her hospital room.       Procedures:  None     Reason for Hospital Admission (Admitting Diagnosis):    ACUTE HYPOXEMIC RESPIRATORY FAILURE COVID 19     If any narcotics was prescribed, I have consulted CURES prior to prescribing.      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 12/3/2023 11:45 AM Author Type Physician Status Addendum Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 11/24/2023  ED to Hosp-Admission (Discharged) on 11/24/2023  ED to Hosp-Admission (Discharged) on 11/24/2023   Revision 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   HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY  PARAPLEGIA  PRESSURE ULCER OF RIGHT HEEL STAGE 2 (PARTIAL THICKNESS SKIN LOSS)  ACUTE HYPOXEMIC RESPIRATORY FAILURE  COVID-19 DISEASE  ISCHEMIC CARDIOMYOPATHY  PRESENCE OF AICD  HTN (HYPERTENSION)  LEUKOCYTOSIS  UTI (URINARY TRACT INFECTION)  ANTICOAGULATION MONITORING, INR 2.0-3.0  DM 2 W CKD STAGE 2 (GFR 60-89 W OTHER KIDNEY DAMAGE MARKER) W HTN  DM 2  ANEMIA  SLEEP APNEA  HX OF STROKE  TOBACCO SMOKER Care Timeline  11/24   Admitted from ED (Observation) 1546 12/03   Discharged 1250  Discharge   Assisted Living Facility or Board & Care or Residential Care   Discharge Instructions (AVS) (Printed 12/3/2023) Medication List at Discharge   acetaminophen 650 mg Oral EVERY 4 HOURS AS NEEDED, . Do not exceed 10 tablets in 24 hours. Do not exceed 4,000 mg of acetaminophen per day from all sources  amiodarone HCl 200 mg Oral DAILY  atorvastatin calcium 40 mg Oral DAILY, to prevent heart attacks and strokes  blood sugar diagnostic Use 3 times a day as directed to measure blood sugar  bumetanide 1 mg Oral DAILY  carvedilol 3.125 mg Oral 2 TIMES A DAY WITH MEALS  docusate sodium 250 mg Oral DAILY, for bowel regularity. Hold for loose stools  empagliflozin 12.5 mg Oral EVERY MORNING  gabapentin 300 mg Oral EVERY BEDTIME  lancets 30 gauge Use 3 times a day as directed to measure blood sugar  losartan potassium 12.5 mg Oral DAILY  oxycodone HCl 5 mg Take 1 tablet by mouth every 12 hours as needed for severe pain. Please fill all regular home meds for board and care placement.  warfarin sodium   1 mg Tab, Take by mouth as directed by Anticoagulation service  Patient on Warfarin and is followed by the Anticoagulation Clinic. Contact Anticoagulation Clinic.