Age: 93.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial fibrillation, COVID-19, Chest X-ray abnormal, Decubitus ulcer, Dehydration
Clinical narrative: Date of Admission: 10/26/2023 12:34 PM   Date of Discharge: 10/30/2023   Issues to be Addressed at Follow-up: Take antibiotics and steroids until gone   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/26/2023  3:15 PM BLOOD CULTURE 2 Preliminary BLOOD   10/26/2023  3:10 PM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION   ? DIASTOLIC HEART FAILURE, ACUTE   ? PRESSURE ULCER OF RIGHT ELBOW STAGE 2 (PARTIAL THICKNESS SKIN LOSS)   ? MODERATE DEHYDRATION   ? HX OF ACUTE KIDNEY INJURY   ? SEPSIS WO ACUTE ORGAN DYSFUNCTION   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? HEART FAILURE W REDUCED LVEF 41-49%, UNSPECIFIED ACUITY   ? COVID-19 DISEASE   ? ATRIAL FIBRILLATION, PAROXYSMAL     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: Patient is a 96yom with PMH of s/dCHF, AFib who presents to facility from SNF due to malaise.  Reportedly, the SNF has several residents test positive for COVID.  He came to ER where he was found to be hypoxic and COVID was positive. His CXR was also suggestive of PNA.  He was started on oxygen, remdesivir, decadron, Ceftriaxone and Doxycycline. By second hospital day patient was weaned off oxygen and had no respiratory symptoms.  He was monitored another 24 hours in hospital on room air and continued to improve and felt ready for DC home.   *ADDENDUM* 12:19 PM 10/30/2023  Patient was unable to return to ALF due to logistics and therefore was able to DC 10/30.   Subjective Accounts on Day of Discharge: No complaints. Ready for DC today.   Vitals on Day of Discharge: BP 131/80  | Pulse 62  | Temp 96.5 °F (35.8 °C)  | Resp 20  | Ht 5' 8"  | Wt 66.5 kg (146 lb 9.6 oz)  | SpO2 98%  | BMI 22.29 kg/m²    Physical Exam on Day of Discharge: General appearance -  alert, elderly and stable appearing, and in no distress Mental Status -  alert, oriented x 3 HEENT: nc/at 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. +BS active all quadrants. Neurological - motor and sensory grossly normal bilaterally Extremities - no clubbing or cyanosis. Peripheral pulses present, pedal edema absent Skin -  warm and dry   Primary Procedures:      Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Acute hypoxemic respiratory failure due to COVID and CAP   Complications: none   Consults:  None   Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR       DO 12:20 PM 10/30/2023     Note Details  Author (D.O.) File Time 10/30/2023 12:20 PM Author Type PHYSICIAN (D.O.) Status Addendum Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 10/26/2023  ED to Hosp-Admission (Discharged) on 10/26/2023  ED to Hosp-Admission (Discharged) on 10/26/2023   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   ATRIAL FIBRILLATION, PAROXYSMAL  HEART FAILURE W REDUCED LVEF 41-49%, UNSPECIFIED ACUITY  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION  COVID-19 DISEASE  NONTRAUMATIC ACUTE KIDNEY INJURY  MODERATE DEHYDRATION  HX OF ACUTE KIDNEY INJURY  SEPSIS WO ACUTE ORGAN DYSFUNCTION  DIASTOLIC HEART FAILURE, ACUTE  PRESSURE ULCER OF RIGHT ELBOW STAGE 2 (PARTIAL THICKNESS SKIN LOSS) Care Timeline  10/26   Admitted from ED 1609 10/30   Discharged 1504  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 10/30/2023) Medication List at Discharge   aspirin 81 mg Oral DAILY  atorvastatin calcium 10 mg Oral DAILY, to prevent heart attacks and strokes  cefpodoxime proxetil 200 mg Oral 2 TIMES A DAY  dexamethasone   8 mg Oral 2 TIMES A DAY, the day before chemo, the day of chemo, and the day after chemo  6 mg Oral DAILY, for 6 days  doxycycline monohydrate 100 mg Oral 2 TIMES A DAY  finasteride 5 mg Oral DAILY  isosorbide dinitrate 5 mg Oral 2 TIMES A DAY  metoprolol succinate 25 mg Take 1 tablet by mouth daily Hold for pulse less than 50 or Systolic Blood Pressure less than 100.  multivitamin 1 tablet Oral DAILY  polyethylene glycol 3350 17 gram/dose Mix 17 Grams in 4 to 8 ounces of water or juice and drink by mouth daily as directed for constipation  sennosides 8.6 mg Oral DAILY, Hold for loose stools  tamsulosin HCl 0.4 mg Oral DAILY