Age: 55.0
Sex: M
Vaccine: COVID19
Symptoms: Diabetic nephropathy, Hallucination, Hypertension, Hyponatraemia, Liver function test increased
Clinical narrative: Date of Admission: 11/11/2023   Date of Discharge: 11/14/2023   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 10/15/2023 to 11/15/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ALCOHOL WITHDRAWAL   ? UNHEALTHY DRINKING BEHAVIOR   ? HX OF TOBACCO USE   ? HTN (HYPERTENSION)   ? OBSTRUCTIVE SLEEP APNEA       Date: 9/25/19  Study Type: WatchPAT  pAHI: 76.7  BMI: 36.62   ESS: 15  Min SpO2: 67% SpO2<90%: 99.1 minutes  Severe Sleep Apnea.   ? SEVERE OBESITY EQUIVALENT (BMI 35-39.9 W CO-MORBIDITY)   ? HX OF COVID-19 DISEASE   ? CHRONIC PANCREATITIS   ? SUICIDAL IDEATION   ? DM 2 W CKD STAGE 3B (GFR 30-44) W HTN   ? HYPONATREMIA   ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE   ? ADJUSTMENT DISORDER W ANXIETY   ? HX OF DUODENAL ULCER     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: 57-year-old male with a history of alcohol abuse, suicidal ideation, medication non-compliance, DM 2, CKD 3, HTN, MDD, adjustment disorder with anxiety, OSA, PUD, tobacco use, hyperlipidemia, and obesity presented with suicidal ideation. In the ED, his alcohol level was 238, and he received Librium to prevent withdrawal. He later experienced alcohol withdrawal (CIWA score 22) and was treated with Lorazepam, Clonidine, and Gabapentin. The patient, living in a car, reported non-compliance with medications, including Atorvastatin, Empagliflozin, and Metformin. He had no abdominal pain, emesis, diarrhea, chest pain, cough, urinary symptoms, fever, chills, or tremors but reported occasional hallucinations. Recent labs showed low Sodium, high anion gap, high glucose, and slightly elevated Creatinine.   Patient was treated with the CIWA protocol with resolution of his withdrawal symptoms, he is stable for discharge, and will follow up with CDRP and AA. He will resume his usual medications, will recommend holding his statin as his LFT's were slightly elevated for now, and also hold metformin due to CKD.      Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  ETOH Withdrawal   Complications: none   Consults:  PSYCHIATRY - INITIAL INPATIENT CONSULTATION. PSYCHIATRY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author  (M.D.) File Time 11/14/2023 10:32 AM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #   Admit Date 11/11/2023  ED to Hosp-Admission (Discharged) on 11/11/2023  ED to Hosp-Admission (Discharged) on 11/11/2023   Detailed Report  Note shared with patient Hospital Problem List   MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE  CHRONIC PANCREATITIS  HX OF DUODENAL ULCER  ADJUSTMENT DISORDER W ANXIETY  HYPONATREMIA  DM 2 W CKD STAGE 3B (GFR 30-44) W HTN  SUICIDAL IDEATION  HX OF COVID-19 DISEASE  ALCOHOL WITHDRAWAL  UNHEALTHY DRINKING BEHAVIOR  HTN (HYPERTENSION)  HX OF TOBACCO USE  SEVERE OBESITY EQUIVALENT (BMI 35-39.9 W CO-MORBIDITY)  OBSTRUCTIVE SLEEP APNEA Care Timeline  11/12   Admitted from ED (Observation) 1056 11/14   Discharged 1500  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/14/2023)