Age: 89.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, High density lipoprotein increased, Hypertension, Low density lipoprotein, Pericardial effusion
Clinical narrative: Date of Admission: 9/10/2023   Date of Discharge: 9/11/2023   Issues to be Addressed at Follow-up: Recovery from COVID Recovery from UTI.   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/10/2023  4:07 PM BLOOD CULTURE 2 In process BLOOD   9/10/2023  3:23 PM BLOOD CULTURE In process BLOOD   9/10/2023  1:38 PM DRAW AND HOLD SERUM, RED TOP TUBE In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? HTN (HYPERTENSION)        BP Readings from Last 3 Encounters: 07/25/22 136/61 07/16/22 144/62 05/31/22 153/64    Lab Results Component Value Date   Creatinine 1.59 (H) 07/16/2022      Lab Results Component Value Date   Potassium 4.3 07/16/2022      Pulse Readings from Last 3 Encounters: 07/25/22 78 07/16/22 59 05/31/22 62   Losartan 25 mg      ? HYPERLIPIDEMIA        Lab Results Component Value Date   Cholesterol 156 03/23/2022   Triglyceride 95 05/01/2015   HDL 70 03/23/2022   Low density lipoprotein calculated 100 05/01/2015   LDL CALCULATED, NONFASTING 61 03/23/2022   TRIGLYCERIDE, NONFASTING 126 03/23/2022       ? BPH (BENIGN PROSTATIC HYPERPLASIA)   ? HYPOTHYROIDISM       8/14/2023  - Results     Lab Results Component Value Date   TSH 1.9 07/31/2023    levothyroxine 200  mcg  Stable clinically,continue current regimen            ? GENERALIZED CONVULSIVE EPILEPSY       From:  (2/3/2019 8:08:29 PM) <<<   Not seen in 3 years. No need for continued neuro follow up and I no longer go to Facility. Please assume prescription or refer as new consult to alternate neurologist in Facility. Thanks   ? PERICARDIAL EFFUSION   ? CHRONIC RESPIRATORY FAILURE       On home Oxygen at night time    ? DIASTOLIC HEART FAILURE, UNSPECIFIED ACUITY   ? COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)       Severe obstructive defect. On PFTs   ? CKD STAGE 3B (GFR 30-44)       CKD Flowsheet Link     Lab Results Component Value Date   CR 1.95 (H) 08/12/2023   GFRESTIM 36 (L) 08/07/2023   GFRESTIM 38 (L) 07/31/2023   GFRESTIM 39 (L) 07/29/2023   PROTCREAT 10.15 (H) 08/12/2023     Avoid nephrotoxic agents ,monitor GFR        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 92 year old male with a history of COPD,chronic hypoxemic respiratory failure on 2 liters supplemental O2, HFpEF, h/o lung cancer, HTN, HLD, hypothyroid, epilepsy, CKD, BPH with self cath, recently diagnosed with COVID and sent to the ER due to SOB.  CXR at presentation without acute findings.  He O2 sat was stable/normal on his baseline O2 supplementation.  He was admitted to Facility and treated with Remdesivir and decadron.  Breathing remained stable with no hypoxia on his baseline O2 supplementation.  He will go home on paxlovid with instructions to hold Primodine and Simvastatin while taking Paxlovid.   He was diagnosed with a UTI as an outpatient on 9/5 and treated with Duricef.  He states that with this treatment his urine cleared and he felt better but the urine culture grew Enterococcus.  He was treated with vanco in the ER and will go home on nitrofurantoin due to PCN and cipro allergy.  Of note patient's PCN allergy was in his 20s when he took PCN for a year for fluid around his lung.  He developed a rash at the end of his treatment.  PCN may be a viable option in the future.     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  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: Full Code       Note Details  Author  (M.D.) File Time 9/11/2023  2:18 PM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/10/2023  ED to Hosp-Admission (Discharged) on 9/10/2023  ED to Hosp-Admission (Discharged) on 9/10/2023   Detailed Report  Note viewed by patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   SmartForms:   STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   CKD STAGE 3B (GFR 30-44)  COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)  DIASTOLIC HEART FAILURE, UNSPECIFIED ACUITY  CHRONIC RESPIRATORY FAILURE  PERICARDIAL EFFUSION  COVID-19 DISEASE  HTN (HYPERTENSION)  HYPERLIPIDEMIA  GENERALIZED CONVULSIVE EPILEPSY  HYPOTHYROIDISM  BPH (BENIGN PROSTATIC HYPERPLASIA) Care Timeline  09/10   Admitted from ED (Observation) 1856 09/11   Discharged 1617  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 9/11/2023)