Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Acute myocardial infarction, Alanine aminotransferase increased, Anaemia, Ankylosing spondylitis, Aspartate aminotransferase normal
Clinical narrative: Date of Admission: 12/11/2023   Date of Discharge: 12/15/2023   Issues to be Addressed at Follow-up: Follow up on COVID  Anemia    Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/11/2023  5:00 PM BLOOD CULTURE 2 Preliminary BLOOD   12/11/2023  4:00 PM URINE CULTURE Preliminary URINE   12/11/2023  4:00 PM BLOOD CULTURE Preliminary BLOOD     Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? UTI (URINARY TRACT INFECTION)   ? URINARY RETENTION   ? ANEMIA   ? NAUSEA AND VOMITING   ? MALAISE AND FATIGUE   ? TYPE 2 MI   ? COLON CANCER, DESCENDING       Added automatically from request for surgery    ? MAJOR VASCULAR NEUROCOGNITIVE DISORDER (VASCULAR DEMENTIA)   ? ANKYLOSING SPONDYLITIS OF UNSPECIFIED REGION OF SPINE   ? HX OF STROKE   ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE   ? HTN (HYPERTENSION)   ? OBSTRUCTIVE SLEEP APNEA       WATCHPAT AMBULATORY SLEEP STUDY  11/17/16   Diagnosis:    MILD OSA (AHI= 13;  Normal < 5; ODI = 6, Min O2 sat 89%; Mean O2 sat =95%; Duration o2 Sat <90% = 0 minutes) ESS = 0 Estimated body mass index is 28.31 kg/(m^2) as calculated from the following:   Height as of 3/29/16: 5' 4".   Weight as of 11/1/16: 165 lb (74.844 kg). REM observed=9 %      Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  SNF   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 81 year old female with a PMHx of stage III colon cancer (pT3pN1) currently on CapeOx chemo , ankylosing spondylitis, anemia, HTN, prior stroke, Depression, Pre-DM, Ha1c 5.8,  OSA, recent admission 12/7 - 12/10 treated for generalized malaise and weakness found to have severe constipation and urinary retention.  During that admission, she had a Foley catheter but was removed prior to discharge and constipation resolved.  Within the first 24 hours of discharge, patient developed fever, congestion, nausea and brought back to ED.  She was admitted again on 12/11,  found to have UTI and COVID-19.  She was initiated on IV antibiotics for UTI and Remdesivir. Urine grew E.coli and finished 5 days course of Ceftriaxone IV, sensitivities still pending. For COVID received only Remdesivir infusion and not hypoxic. Patient had GI symptoms predominant COVID-19.  Respiratory status remained stable.   Seen by PT and discharge to SNF. Updated discharge plan to daughter via phone.    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  COVID -19 UTI   Complications: none   Consults:  HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     PROGRESS NOTE : HBS   Subjective: Feels fine and had breakfast in morning . Denies cough and SOB Last night had lower back pain probably from  lying down. States " Tylenol took care of it , i don't have pain now  " .   Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 12/15/23 0832 97.3 °F (36.3 °C) Oral 89 135/68 18 96 % RA 12/14/23 2357 98.2 °F (36.8 °C) Oral 75 112/48 18 96 % RA 12/14/23 1610 97.8 °F (36.6 °C) Oral 76 123/59 18 97 % RA     Intake/Output Summary (Last 24 hours) at 12/15/2023 1118 Last data filed at 12/15/2023 0833  Gross over last 24 hours Intake 1015 ml Output 2200 ml Net -1185 ml   Patient Vitals for the past 72 hrs:    Stool Characteristics Unmeasured Stool (#) 12/15/23 1100 Large;Soft;Brown 1 12/14/23 1730 Large;Soft;Brown 2 12/13/23 2306 Brown;Soft;Medium 1 12/13/23 1830 Brown;Formed;Large 1   General appearance - alert, frail, and in no distress Mental Status - alert, oriented x 3 forgetful  Chest - clear to auscultation, no wheezes, rales or rhonchi Heart - regular rate and rhythm Abdomen - soft, nontender, nondistended, BS+ Extremities - no edema Spine; no point tenderness on exam    Selected Lab Results:   Recent Labs   12/15/23 0656 12/14/23 0645 12/13/23 0707 12/12/23 0726 12/11/23 1700 WBC 4.2 3.3* 3.1* 5.3 6.0 HGB 8.7* 8.8* 8.5* 9.0* 9.6* HCT 27.1* 26.5* 25.7* 25.9* 29.3* PLT 187 190 183 179 189 MCV 90 90 89 88 91      Recent Labs   12/11/23 1925 12/11/23 1700 TROP 18* 13*      Recent Labs   12/15/23 0656 12/14/23 0645 12/13/23 0707 12/12/23 0726 12/11/23 1600 12/10/23 0620 12/09/23 0711 NA 140 138 136 134* 131* 139 140 K 4.3 4.2 3.9 3.8 4.6 4.0 4.5 CO2 27 27 26 24 24 28 27 CL 106 104 101 99* 97* 104 106 BUN 21 24 21 12 14 11 10 CR 0.71 0.69 0.86 0.73 0.81 0.71 0.68 RBS 104 119 116 109 138 116 107 CA  --   --   --   --  8.4*  --   --  PHOS 3.7  --   --   --   --  3.1 2.6* MG 2.0  --   --  1.8 1.8 2.0 2.0     No results for input(s): "PT", "INR", "PTT", "HEPUNFR" in the last 168 hours.    Recent Labs   12/15/23 0656 12/14/23 0645 12/13/23 0707 12/12/23 0726 12/11/23 1600 AST 21 30 49* 64* 50* ALT 42* 56* 70* 65* 38 ALKP  --  43 43 46 51 TBILI  --  0.2 0.2 0.3 0.5 LIPASE  --   --   --   --  30   CT HEAD: No acute intracranial findings   CXR: No acute disease   Assessment and Plan: Patient Active Hospital Problem List:  COVID-19 DISEASE (12/11/2023)  NAUSEA AND VOMITING (12/7/2023)  MALAISE AND FATIGUE (12/7/2023)              Assessment: Appears patient has GI symptoms predominant COVID-19.  Respiratory status appears stable.              Immunocompromise status .                Plan:             Received Remdesivir for 4 days              Not on steroids since not hypoxemic     UTI (URINARY TRACT INFECTION) (12/11/2023)              Assessment: Noted               Plan:             Ceftriaxone 1 g daily x 5 doses .       HTN (HYPERTENSION) (12/6/2017)              Assessment: Stable               Plan:             Lisinopril   MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE (1/4/2019)              Assessment: Noted              Plan:             C/w Wellbutrin   HX OF STROKE (6/12/2022)              Assessment: Noted              Plan:             C/w Atorvastatin            Not on ASA ( Bleeding risk )    MAJOR VASCULAR NEUROCOGNITIVE DISORDER (VASCULAR DEMENTIA) (7/24/2023)              Assessment: Noted              Plan:             Delirium precautions           C/w  Seroquel, Abilify, Amantadine   COLON CANCER, DESCENDING (8/16/2023)              Assessment: Currently on chemotherapy including Xeloda.  Dr. has been in close contact with daughter and most recently recommended stopping chemotherapy since patient is not tolerating.              Plan:             Hold Xeloda as per Dr.'s recommendations             Outpatient follow-up  ANEMIA            Assessment: Denies bleeding , Melena or hematochezia   Hgb Date/Time Value Ref Range Status 12/15/2023 06:56 AM 8.7 (L) 11.5 - 15.0 g/dL Final 12/14/2023 06:45 AM 8.8 (L) 11.5 - 15.0 g/dL Final 12/13/2023 07:07 AM 8.5 (L) 11.5 - 15.0 g/dL Final 12/12/2023 07:26 AM 9.0 (L) 11.5 - 15.0 g/dL Final 12/11/2023 05:00 PM 9.6 (L) 11.5 - 15.0 g/dL Final            Plan:            Monitor CBC    ANKYLOSING SPONDYLITIS OF UNSPECIFIED REGION OF SPINE (1/14/2023)              Assessment: Noted              Plan: Outpatient management            Tylenol PRN for pain    H/o PREDIABETES MELLITUS            Assessment :Recent Ha1c   Hgb A1c % Date Value Ref Range Status 08/04/2023 5.8 (H) <=5.6 % Final 11/28/2022 5.9 (H) <=5.6 % Final 04/20/2022 6.3 (H) <=5.6 % Final .          Plan :            Restart Metformin.            1800 ADA            No need for SSI coverage     URINARY RETENTION (12/8/2023)              Assessment: Patient noted to have urinary retention on the previous admission in which required Foley catheter              Plan: Serial PVR   PPI  FOR GI PROPHYLAXIS   DVT PROPHYLAXIS WITH LMWH PLT:187   OBSTRUCTIVE SLEEP APNEA             Assessment: Noted            Plan: c/w CPAP at night   Lives alone PT eval    DISPO: D/c to SNF when bed available .  Updated discharge plan to daughter in detail and confirmed discharge meds with her.                          Note Details  Author (M.D.) File Time 12/15/2023 11:26 AM Author Type Physician Status Addendum Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 12/11/2023  ED to Hosp-Admission (Discharged) on 12/11/2023  ED to Hosp-Admission (Discharged) on 12/11/2023   Revision History   Detailed Report  Note shared with patient Hospital Problem List   HTN (HYPERTENSION)  MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE  ANKYLOSING SPONDYLITIS OF UNSPECIFIED REGION OF SPINE  MAJOR VASCULAR NEUROCOGNITIVE DISORDER (VASCULAR DEMENTIA)  COVID-19 DISEASE  OBSTRUCTIVE SLEEP APNEA  HX OF STROKE  COLON CANCER, DESCENDING  NAUSEA AND VOMITING  MALAISE AND FATIGUE  TYPE 2 MI  ANEMIA  URINARY RETENTION  UTI (URINARY TRACT INFECTION) Care Timeline  12/11   Admitted from ED 2307 12/15   Discharged 1322  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 12/15/2023)   Follow-Ups: Follow up    Discharge Orders  AST  ALT