Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Left ventricular failure, Leukocytosis, Lumbar vertebral fracture, Lung opacity, Mental status changes
Clinical narrative: Attestation signed by (M.D.) at 10/25/2023  4:17 PM   I have reviewed and verified the content of this Discharge Summary. The Discharge Summary accurately reflects the outcome of the patient?s hospitalization and/or treatment, the disposition of the patient, and the patient?s final diagnosis. I have verified that the Discharge Summary also provides for appropriate follow-up care to facilitate proper continuity of care.    Date of Admission: 10/15/2023   Date of Discharge: 10/25/2023   Issues to be Addressed at Follow-up: HOSPICE CARE   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 9/22/2023 to 10/23/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? AV BLOCK, COMPLETE   ? DELIRIUM DUE TO MULTIPLE ETIOLOGIES   ? AORTIC VALVE STENOSIS       Severe by TTE 10/16/23   ? ACUTE CHF W LVEF UNKNOWN, UNSPECIFIED   ? LUMBAR VERTEBRAL FX   ? TYPE 2 MI   ? COVID-19 DISEASE   ? EMPHYSEMA       CT abd pelvis 4/14/2022   ? HYPOTHYROIDISM   ? PRESENCE OF CARDIAC PACEMAKER       3/10/15 Boston Scientific Vitalio K274 409141 RA: Guidant bi 4136 29591805 0.5 v at 0.5 ms, 2.7 mV, 505 ohms RV: Guidant bi 4457 Passive lead 0.4 v at 0.4 ms, 8.8 mV, 543 ohms DDD 60-120 Not MRI compatible Pacemaker Dependent   ? ATHEROSCLEROSIS AORTA   ? BPH (BENIGN PROSTATIC HYPERPLASIA)   ? HYPERTENSION       bblocker caused bradycardia Clonidine caused bradycardia       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Hospice   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 92 Y male with h/o AV Block s/p cardiac pacemaker implantation in 2015, HTN, BPH, AOA, hypothyroidism, and emphysema who presented to ED on 10/13 and 10/15 with worsening back pain after sustaining fall on back and ultimately found to have +CT finding of an unstable L5 vertebral ftx deemed inoperable by neurosurgery due to his comorbities (ie. Aortic stenosis, DHF) and recommended to wear a TSLO brace. Patient was also found to be hypoxic (76%) on RA with wet CXR and mildly elevated trops in 300s thought to be d/t demand ischemia later discovered to not be adherent to home HF medications so, given 40mg IV Lasix 6x from 10/15-10/17 with good response. On HD#2, he became newly altered above baseline likely multifactorial given his baseline dementia, +COVID infection, acute CHF exacerbation, and current hospitalization environment although he also presented with new onset leukocytosis. Also, despite adequate UOP from diuresis, patient still required elevated O2 requirements of 5.5L (despite not being on O2 at home) so a repeat CXR was done and was significant for multiple opacities as compared to last so, started on IV Ceftriaxone 2g daily + IV Doxycycline 100mg bid for CAP. Delirium eventually improved mid-hospitalization and cycled up and down throughout suspected d/t Decadron and Oxycodone treatments so, Oxycodone held for 1 day during an acute delirium phase which eventually led return to near baseline on 10/23. TTE (10/16) shows normal EF (55-60%) with mild dilatation of atria although assessment of LV diastolic function limited so still likely an acute CHF although difficult dgx given no prior TTE to compare. His leukocytosis was also thought to be due to him being on Decadron for his current COVID infection. Eventually, leukocytosis resolved on HOD#3 with gradually decreasing O2 requirements to 2L. Patient was held until 10/25/22 due to COVID isolation requirements of 10 days before the hospice facility would be able to accept him for transfer. As a result, patient's pain and comfort care protocol was prioritized with successful removal of staples prior to discharge.   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  UNSTABLE L5 VERTEBRAL FRACTURE  ACUTE HYPOXEMIC RESPIRATORY FAILURE DIASTOLIC HEART FAILURE COMMUNITY ACQUIRED PNEUMONIA   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. PALLIATIVE CARE - INITIAL INPATIENT CONSULTATION. PALLIATIVE CARE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR ____________________________ D.O. | PGY-1 Family Medicine Residency Hospital Based Medicine         Cosigned by: (M.D.) at 10/25/2023  4:17 PM  Note Details  Author (D.O.) File Time 10/25/2023  4:17 PM Author Type PHYSICIAN, RESIDENT Status Addendum Last Editor (D.O.) Specialty GENERAL, OTHER  Admit Date 10/15/2023  ED to Hosp-Admission (Discharged) on 10/15/2023  ED to Hosp-Admission (Discharged) on 10/15/2023   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   HYPERTENSION  ATHEROSCLEROSIS AORTA  HYPOTHYROIDISM  EMPHYSEMA  DELIRIUM DUE TO MULTIPLE ETIOLOGIES  ACUTE HYPOXEMIC RESPIRATORY FAILURE  BPH (BENIGN PROSTATIC HYPERPLASIA)  PRESENCE OF CARDIAC PACEMAKER  ACUTE CHF W LVEF UNKNOWN, UNSPECIFIED  LUMBAR VERTEBRAL FX  TYPE 2 MI  COVID-19 DISEASE  AORTIC VALVE STENOSIS  AV BLOCK, COMPLETE Care Timeline  10/15   Admitted from ED (Observation) 1357 10/22   Admitted 1606 10/25   Discharged 1046  Discharge   Home with Hospice   Discharge Instructions (AVS) (Printed 10/25/2023) Medication List at Discharge   acetaminophen 650 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  amlodipine besylate 10 mg Oral DAILY  atropine sulfate 1 % Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT". Do not dispense with ophthalmic route instruction  bisacodyl 10 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  docusate sodium 250 mg Take 1 capsule by mouth daily for bowel regularity. Hold for loose stools  finasteride 5 mg Oral DAILY  haloperidol 1 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  latanoprost 0.005 % 1 Drop Both eyes EVERY BEDTIME, for Glaucoma  levothyroxine sodium 25 mcg Oral DAILY BEFORE BREAKFAST  lisinopril 20 mg Oral DAILY  lorazepam 0.5 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  metoprolol succinate 50 mg Oral DAILY  morphine sulfate 100 mg/5 mL (20 mg/mL) Use as directed by hospice medical staff. Please supply with two 1 mL oral syringes or 1 mL syringes without needle. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  phenobarbital 97.2 mg Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  sennosides 8.6 mg TAKE 1 TABLET ORALLY WITH EACH NARCOTIC DOSE FOR BOWEL REGULARITY. NOT TO EXCEED 8 TABLETS IN 24 HOURS. HOLD FOR LOOSE STOOLS  surgical lubricant Use as directed by hospice medical staff. This medication is ordered as part of a home hospice kit. Place this medication in a separate sealed bag labeled "HOSPICE C-KIT".  tamsulosin HCl 0.4 mg Oral DAILY  trospium chloride 20 mg Oral EVERY BEDTIME