Age: 63.0
Sex: M
Vaccine: COVID19
Symptoms: Gastrooesophageal reflux disease, Glycosylated haemoglobin increased, Hiatus hernia, Hypophagia, Ileus
Clinical narrative: Patient is a 63 y.o. male patient of MD with PMH of CAD, HTN, HLD, obesity, neurogenic bladder, DM presented to the ED due to not feeling well and abdominal pain.    Abdominal pain, improving  Diarrhea, resolved  CT scan showing dilation of mostly small bowel loops with air fluid levels, consider ileus vs obstruction. WBC 15.23 (12/26) -- > 9.83 (12/29) Surgery consulted, pt not clinically obstructed, no acute intervention, signed off Stool negative for C diff Blood cultures drawn in ED: NG @ 48 hrs Sx improving, tolerating a diet without vomiting/diarrhea (12/27-29)  Pt reports mild sensation of bloating when eating (12/28-29). Denies pain, inability to swallow or regurgitation of food. EGD 03/2022 reviewed, noted reflux esophagitis, Barrett's esophagus, small hiatal hernia. On PPI as below. Recommended patient eat smaller portions at time, avoid caffeine/carbonated beverages, sit up when eating. OP f/u.    AKI, resolved  Cr 1.75 (12/27) from 1.22 (12/26) In setting of GI losses, decreased oral intake, IV contrast  Hold entresto, torsemide. Giving gentle IVF Cr 1.59 (12/28), Cr 1.22 (12/29) Pt no longer with diarrhea/vomiting. Tolerating PO intake. Plan to restart torsemide 1 day after discharge, entresto following day. D/w patient.  Close PCP f/u, BMP within 1 week.   UTI suspected due to SPC, POA Neurogenic bladder UA concerning for infection, however collected in SPC SPC has not been exchanged since August per patient Urology c/s: s/p cath exchange evening of 12/26 Discussed with Dr from Urology, CM c/s and HHC set up for monthly exchanges Already received IV antibiotics, continue rocephin Urine cx w/ probable contamination WBC improving as above, continuing Rocephin while inpatient, will discharge on Cefdinir to complete course   Covid-19 Virus Infection Date of onset of symptoms: 12/26       Symptoms present on admission: diarrhea, weakness Date of covid positive test: 12/26 Vaccination status: vaccinated Imaging: CT personally reviewed showing no acute pulmonary process in lower lung lobes.  Oxygen requirements on admission: Room air Current oxygen requirements: Room air Medical therapy: not indicated Consultants following: econsult for ID for paxlovid, not indicated given lack of symptoms  Anticipated special isolation end date: 1/4/23 Discussed with patient (12/29)   Diabetes Mellitus A1c 8.5 Home regimen: Lantus 35U every morning, SSI Will continue lantus at reduced dose, SSI Lantus gradually increased as patient increased PO intake Continue home regimen at discharge    OSA CPAP at bedtime   CAD HFrEF with chronic respiratory failure Patient has pulse ox, supplemental O2 at home. States he has not been using and has not had shortness of breath. ECHO in 4/2022 showing EF 40 +/- 5%, improved from prior Continue home BB, statin and Plavix.   Entresto, torsemide held for AKI. Restart as planned above  On RA throughout admission PCP and Cardiology f/u    Hypothyrodism Synthroid. Essential HTN Continue home Coreg, Norvasc Entresto held as above PRN Hydralazine    GERD Omeprazole continued as protonix    Morbid obesity  BMI 50 Recommend weight loss   R shoulder pain Chronic, stable per patient OP follow-up   Discharge needs CM c/s: HHC set up for catheter exchanges.  Discussed with CM, patient does have a case manager available through his insurance. Call placed by CM to patient's insurance  regarding establishing improved follow-up given patient's limited transportation availability.