Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Alanine aminotransferase normal, Ammonia increased, Aspartate aminotransferase normal, Atrial fibrillation, Blood alkaline phosphatase increased
Clinical narrative: (M.D.)  Physician Specialty:  Hospital Medicine Discharge Summary    Signed  Signed    Date of Admission: 11/30/2023   Date of Discharge: 12/11/2023   Issues to be Addressed at Follow-up: Continued management of CHF and monitoring for volume status on higher dose of Bumex 2 mg bid   Continued work up of possible cirrhosis and hepatic encephalopathy -- > referral for fibroscan sent and f/u w/ the GI clinic   Continued work up and mgt of possible early dementia -- > econsult to memory care clinic sent     Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 11/11/2023 to 12/12/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) DIASTOLIC HEART FAILURE, ACUTE ON CHRONIC   ? HEART FAILURE W NORMAL LVEF >=50%, UNSPECIFIED ACUITY   ? DELIRIUM   ? HEPATIC ENCEPHALOPATHY   ? COVID-19 DISEASE   ? SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION   ? DM 2 CONTROLLED BY DIET       3/10/2023 Luttio - DOV   Lab Results Component Value Date   Hgb A1c % 6.1 (H) 09/28/2022   As per recent pharmacy telephone note, consider Jardiance as per HF, HTN, DM.  Currently DM diet controlled (A1c 6.8% in 2016, and recent 6.5%). Some dizziness in the AM, today heart rate controlled and TMs clear (some cerumen right EAC). Discussed consider adding Jardiance, patient to discuss further with PCP. PGE forms as per concentrator to go to ROMI and PCP, reports not consistently using CPAP. Discussed limit sodium (not just added table salt), BP borderline elevated today 138/81mmHg.     ? ANTICOAGULATION MONITORING, INR 2.0-3.0       Start date: 8/5/22  Indication: Atrial fibrillation. INR goal range: 2.0-3.0.  End date: Life-long (provider to asses risk vs benefit periodically). Anticoagulation Service.      ? LONG TERM ANTICOAGULANT THERAPY       Started 8/5 as patient could not afford Pradaxa ($122/month based on her insurance)   ? ADULT OBSTRUCTIVE SLEEP APNEA   ? OBESITY HYPOVENTILATION SYNDROME        Recent Labs   07/19/21 1012 PH 7.35 PCO2 92* PO2 63* HCO3 49.5* BE 20.2* O2SAT 89.3*    Wt Readings from Last 1 Encounters: 07/19/21 168.2 kg (370 lb 14.4 oz)       ? ATRIAL FIBRILLATION, PERMANENT W PROTHROMBOTIC STATE   ? CHRONIC HYPERCAPNIC RESPIRATORY FAILURE   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? SEVERE OBESITY (BMI >= 40)   ? HYPERLIPIDEMIA                                ? HYPOTHYROIDISM       Uncontrolled     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   67 y/o F w/ known morbid obesity, OSAS (non-compliant w/ use of CPAP), chronic hypoxemic resp failure on 2 lit of O2 at home, obesity hypoventilation syndrome, diastolic CHF, DM.    Presented w/ SOB and was admitted for tx of both CHF exacerbation and COVID PNA. She was also retaining CO2. She initially required BIPAP then switched to high flow. She was diuresed, as well as started on RDV and decadron (completed course in the hospital). With continued diuresis, she was able to wean down to 3 lit of O2.    Of note, during this hospitalization, pt was developed delirium felt to be multifactorial but also due to hepatic encephalopathy as her NH3 level was elevated. Work up for cirrhosis showed nodular contour of the liver on US. Pt w/ multiple risks factors for cirrhosis including fatty liver and hx of ETOH use. Case was discussed w/ GI who recommended doing a fibroscan (appt made for 1/2/2024). She was treated w/ lactulose w/ improvement in her delirium. Though her NH3 level was elevated on discharge, she clinically is not manifesting symptoms of encephalopathy.    She was discharged in a stable condition with instructions to take a higher dose of Bumex 2 mg po bid. She was advised complete ETOH cessation.    Follow up with PCP is advised within 1 week.    ----------------   Exam on day of discharge: O: BP 118/82  | Pulse 97  | Temp 97.8 °F (36.6 °C)  | Resp 19  | Ht 5' 9"  | Wt 145.2 kg (320 lb)  | SpO2 97%  | Breastfeeding No  | BMI 47.26 kg/m²  Temp (24hrs), Avg:98.1 °F (36.7 °C), Min:97.8 °F (36.6 °C), Max:98.4 °F (36.9 °C)   Gen: awake, alert, NAD MS: conversant, appropriate Chest: decreased BS Heart: RRR Abd: soft, obese Ext: no edema   Selected Lab Results: Electrolytes  Recent Labs   12/11/23 0500 12/10/23 0500 12/09/23 0546 NA 139 140 139 K 4.1 4.3 3.7 CO2 >45* >45* >45* CL 83* 83* 81* BUN 34* | 34* 29* 28* CR 0.56 | 0.56 0.53 0.55 RBS 108 | 108 106 133 MG 2.3 2.2 1.9   CBC  Recent Labs   12/11/23 0500 12/10/23 0500 12/09/23 0546 WBC 11.5* 10.7 9.4 HGB 14.2 14.1 14.1 HCT 45.9 45.7 45.2 PLT 214 214 215 MCV 96 97 96 NEUT 82 81 77 LYMPH 9 | 1.0 8 | 0.9 10 | 1.0 MONO 0.8 | 7 0.9 | 8 0.9 | 9 EOS 1 | 0.2 2 | 0.2 3 | 0.2   Cardiac No results for input(s): "CPK", "CKMB", "TROP", "BNP" in the last 72 hours. LFTs  Recent Labs   12/11/23 0500 AST 33 ALT 36 ALKP 130* TBILI 1.9*   Coags  Recent Labs   12/11/23 0500 12/10/23 0500 12/09/23 0546 PT 25.4* 25.8* 24.6* INR 2.3 2.4 2.2         Primary Procedures:  None   Secondary Procedures: US RUQ    Impression  Limited exam. Questionable mild liver surface contour nodularity. Correlate with risk factors for chronic liver disease.    Cholelithiasis. No definite wall thickening or pericholecystic fluid suggest acute cholecystitis.   ECHO    ?  Left Ventricle: Normal systolic function with an estimated EF of 65 - 70%. ?  Right Ventricle: Right ventricle is severely dilated. Moderately reduced systolic function. ?  Left Atrium: Left atrium is severely dilated. ?  Right Atrium: Right atrium is severely dilated. ?  The PASP is estimated to be 57 mmHg which is elevated based on an estimated RAP of 15 mmHg. ?  IVC/SVC: Dilated (>2.1 cm) IVC size with less than 50% collapse, estimated right atrial pressure of 15 mmHg (elevated).     Reason for Hospital Admission (Admitting Diagnosis):  SOB, acute on chronic hypoxemic resp failure d/t CHF exacerbation and COVID   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Partial Code        Note Details  Author (M.D.) File Time 12/11/2023  4:44 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 11/30/2023  ED to Hosp-Admission (Discharged) on 11/30/2023  ED to Hosp-Admission (Discharged) on 11/30/2023   Routing History   Detailed Report  Note shared with patient Hospital Problem List   HYPOTHYROIDISM  HYPERLIPIDEMIA  SEVERE OBESITY (BMI >= 40)  ATRIAL FIBRILLATION, PERMANENT W PROTHROMBOTIC STATE  CHRONIC HYPERCAPNIC RESPIRATORY FAILURE  OBESITY HYPOVENTILATION SYNDROME  ADULT OBSTRUCTIVE SLEEP APNEA  DM 2 CONTROLLED BY DIET  HEPATIC ENCEPHALOPATHY  DIASTOLIC HEART FAILURE, ACUTE ON CHRONIC  ACUTE HYPOXEMIC RESPIRATORY FAILURE  LONG TERM ANTICOAGULANT THERAPY  ANTICOAGULATION MONITORING, INR 2.0-3.0  COVID-19 DISEASE  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION  DELIRIUM  HEART FAILURE W NORMAL LVEF >=50%, UNSPECIFIED ACUITY Care Timeline  12/01   Admitted from ED (Observation) 1750 12/02   Admitted 1604 12/11   Discharged 1517  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 12/11/2023)