Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Anion gap, Anticoagulant therapy, Arrhythmia, Atrial fibrillation, Bacteraemia
Clinical narrative: Date of Service Aug-09-2022 0621; Date of Admission; Admit Date: Aug-02-2022; Date of Discharge; Date of discharge Aug-09-2022; Allergies; Penicillins - Not Specified; Sulfa Antibiotics - Not Specified; Chief Complaint Nausea, vomiting and chills; Final Diagnoses Infection of skin and/or subcutaneous tissue,Acute urinary tract infection, Procedure(s) Performed, None, Lab Results, Aug-08-2022 1514, Rad, 1610163  Aug-08-2022 0650 Chemistry GLUCOSE  93BUN  36CREAT  0.9MDRD GFR  59NA  142K  4.0CL  107CALCIUM  7.5CO2  28.8OSMO  291.1ANION GP  10.2BUN/CRE  40.0CRP  4.00, Aug-08-2022 0650, Hematology, WBC  8.4RBC  4.65HGB  13.2HCT  40.7MCV  87.5MCH  28.4MCHC  32.4RDW  15.5RDWSD  49.3PLT  202MPV  10.3AUTONEU%  64.5AUTOLYM%  18.4AUTOMON%  12.4AUTOEOS%  2.4AUTOBAS%  0.2AUTONEU#  5.4AUTOLYM#  1.6AUTOMON#  1.0AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.18IG%  2.1; Aug-08-2022 0650; Serology PROCALC  1.15, Imaging Results, IMAGING REPORT, Diagnostic radiology, p.c. Patient Name: Date of Exam: 8/08/2022; Gender: F; Ordering Physician: DO; Exam Description: CH-CHEST PORTABLE 1V DR; EXAM: CH-CHEST PORTABLE 1V DR; INDICATION: PICC line placement TECHNIQUE: AP semierect portable chest obtained at 1441 hours.; COMPARISON: None. CT chest 8/4/2022 8/2/2022 and 7/15/2021 chest x-ray.; FINDINGS:; Left upper extremity PICC coiled in the left axilla. Catheter should be pulled back and readvanced. Cardiac monitor leads overlie the chest. Cardiac silhouette is enlarged accentuated by markedly lordotic and semierect projection. Calcified granulomas left lung base. Low lung volumes. IMPRESSION:1. Malpositioned left upper extremity PICC. The catheter should be pulled back and readvanced. 2. Low lung volumes. 3. Prior granulomatous disease. 4. Markedly lordotic projection, DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 8/8/2022 3:11 PM CDT Functional Status* Impaired mobility (Bedbound) Mental Status*Normal Cognition; Social History; tobacco use; Never Smoked, Smoking Cessation No; marital status; Widowed; Health Concerns Infection of skin and/or subcutaneous tissue; Acute urinary tract infection; Father Deceased Malignant tumor of prostate @ 82; Mother Deceased Lymphoma finding @ 82; Tobacco Cessation*; Non-Smoker, Non Tobacco product user; Vital Signs Aug-09-2022 0300; HR 84 RR 20 BP   112 / 73 O2Sat 98; Aug-08-2022 2300; HR 82 RR 19 BP   118 / 70 O2Sat 98 Aug-08-2022 1900; T 98.8; Aug-08-2022 1501; T 98.9; PHYSICAL EXAM; CONSTITUTIONAL: Patient appears comfortable and in no acute distress, She jokes with me during  my visit. CARDIOVASCULAR: Heart has irregular rate rhythm, pulses are 2/2 in the upper extremities, +2 edema noted; RESPIRATORY: Lungs clear to auscultation throughout and respiratory effort is non-labored GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive; GENITOURINARY:  Patient has a Foley draining pink urine. NEUROLOGICAL: Patient is alert and generally oriented. Sensation is grossly intact PSYCHIATRIC: Patient's mood is euthymic, affect is appropriate. RASS of 0. Hospital Course A 89-year-old female who presented to our facility with symptoms of illness and hypoxic respiratory failure. She was admitted by the Internal Medicine service on 8/3/2022. She was found to be COVID positive and was given remdesivir and dexamethasone. She was initiated on meropenem at 1st due to perceived resistance which was then stepped down to ceftriaxone after urinary cultures and Gram-negative rods which were susceptible to ceftriaxone. Patient's blood cultures grew a g positive cocci on 4/4 bottles. Patient was initiated on azithromycin and vancomycin. Patient has a chronic wound which is believed to be her source which is managed outpatient by Dr. A echocardiogram was performed for risk endocarditis which was negative. Throughout her stay patient is atrial fibrillation with rate control by metoprolol. Metoprolol was increased to 75 mg b.i.d. which her pressures tolerated well. Patient was initiated on Eliquis for paroxysmal atrial fibrillation. Patient developed hematuria and Eliquis was held until patient discharged. Patient's cultures returned with an atypical species: After the decision to treat for 2 additional weeks with vancomycin, patient was given a midline IVC. Orders were sent for administration vancomycin at the nursing home where she will be discharged to. Trough testing was also ordered to be completed outpatient. Patient was scheduled visit Dr. for her hematuria. Patient was discharged on 08/09/22. Condition at Discharge; Stable; Discharge Medications; APIXABAN 5 MG ORALLY TWICE DAILY; Aspirin Adult Low Dose Oral Tablet Delayed Release 81 MG 81 MG ORALLY ONCE A DAY; BENZONATATE 100 MG ORALLY EVERY 4 HOURS AS NEEDED for COUGH; Bisacodyl Laxative Rectal Suppository 10 MG 10 MG PER RECTUM ONCE A DAY AS NEEDED for CONSTIPATION; Calcium Oral Tablet 500 MG 500 MG ORALLY ONCE A DAY; Docusate Sodium Oral Capsule 100 MG 100 MG ORALLY TWICE DAILY for CONSTIPATION; Famotidine Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY for OTHER (SEE COMMENTS); Fluoxetine HCl Oral Capsule 40 MG 40 MG ORALLY ONCE A DAY; Folic Acid Oral Tablet 400 MCG 400 MCG ORALLY ONCE A DAY; Linzess Oral Capsule 145 MCG 145 MCG ORALLY ONCE A DAY; Lisinopril Oral Tablet 20 MG 20 MG ORALLY TWICE DAILY; Meloxicam Oral Tablet 7.5 MG 7.5 MG ORALLY ONCE A DAY; METOPROLOL TARTRATE 75 MG ORALLY TWICE DAILY; Milk of Magnesia Oral Suspension 400 MG/5ML 30 ML ORALLY ONCE A DAY AS NEEDED for CONSTIPATION; Movantik Oral Tablet 25 MG 25 MG ORALLY ONCE A DAY;Mylanta Suspension 200-200-20 mg/5ml 30 ML ORALLY EVERY 4 HOURS AS NEEDED for DYSPEPSIA; Nystatin Powder 1 APP TOPICAL ONCE A DAY AS NEEDED for RASH, Polyethylene Glycol 3350 Powder 17 GM ORALLY ONCE A DAY, Oral Capsule 8.6 MG 2 TAB ORALLY EVERY 48 HOURS AS NEEDED for CONSTIPATION. Synthroid Oral Tablet 50 MCG 50 MCG ORALLY ONCE A DAY; Tylenol Oral Tablet 325 MG 650 MG ORALLY EVERY 6 HOURS AS NEEDED for FEVER OR MILD PAIN 1-3 ON PS. VANCOMYCIN HCL 1 GM 1250 MG IV PIGGYBACK EVERY 24 HOURS; SODIUM CHLORIDE 0.9% BAG 250 ML Discharge Disposition. Transfer to skilled nursing facility (SNF) Plan-Acute respiratory failure with hypoxemia, resolved-Covid 19 viral pneumonia, stable-Bacterial urinary tract infection with gram negative rods, resolved-Bacteremia of the blood with gram positive rods (4/4 bottles), improved and treating-Infection of the right ankle, chronic-Atrial fibrillation, paroxysmal-History of recurrent urinary tract infection-Obesity hypoventilation syndrome-Morbid obesity-Bedbound status-Hypothyroid disorder-Compression fractures of the spine at multiple levels. Plan: Treatment of blood infection: - IVC should be used for Vancomycin dosing. It must remain in place for the duration of the therapy, and if removal is deemed necessary, physician guidance should be sought.-Patient will require Vancomycin for 2 weeks duration with last dose on 8/23/22. On 8/29/22, 6 days after patient stopped antibiotics, patient will have blood cultures drawn from two sites. If cultures positive notify physician for probable resumption of antibiotics and transesophageal echocardiogram. - Patient will require a blood draw for Vancomycin trough testing on 8/11/22 at 8:30 am or 30 minutes BEFORE vancomycin is dosed for that day. Patient's current dosing is 1.25 g daily in the morning at 9:00 am. Hematuria:-Patient is scheduled for a follow up at the earliest available appointment for Dr. urology, on Aug 30th at 11:30 AM. Atrial fibrillation: Now on Metoprolol 75 mg BID and Eliquis 5 mg BID; Chronic wound:- Continued care with Dr. on an outpatient basis. Primary Care Provider; DO; Electronically signed by RESIDENT on Aug-09-2022 1355.