Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Sputum discoloured, Staphylococcus test positive, Transfusion
Clinical narrative: 79 y.o.   Admit Date:  7/21/2022   Discharge Date:  7/28/2022    Principal Dx/ Final Dx: Pneumonia of left lower lobe due to infectious organism   Relevant Inpt Dx: Principal Problem:   Pneumonia of left lower lobe due to infectious organism Active Problems:   Hypothyroidism   COVID-19   Acute renal failure superimposed on stage 3 chronic kidney disease   Coag negative Staphylococcus bacteremia   T2DM (type 2 diabetes mellitus)   Benign essential HTN       Follow-up Recommendations: #1 please take medication as prescribed #2 please keep follow-up appointments   HPI: As per Dr Note:  "Patient is a 79 y.o. female who presents to ED with c/o cough, fever and shortness of breath for 4-5 days. Was seen on 7/18 and COVID + (had 1 dose J&J). Had blood cx then with 2/4 bottles coag neg staph, was called back to ED. States she has been feeling worse, now having thick yellow sputum production. Not eating/drinking well. Does have h/o CKD, her Cr is above baseline, also has LLL infiltrate. ED workup more c/w bacterial pneumonia but also has COVID, will admit. Family at bedside and assists w/history."   Hospital Course:   Patient presented with cough and shortness breath. She was found to have left lower lobe pneumonia related to Covid 19 infection. She was also found to have Haemophilus influenza in her sputum cultures. MRSA screen was positive. She was started on empiric antibiotics which were gradually weaned to Omnicef and doxycycline based on culture and sensitivity data. She completed the course of ampicillin and Decadron. Gradually her symptoms improved and was considered suitable for discharge home. Rehabilitation/nursing home placement was offered but family preferred to take him home with home health services. During her hospital stay her hemoglobin dropped to 6.6 requiring one unit of blood transfusion. She was evaluated by gastroenterology and no EGD was recommended at this time. Her hemoglobin remained stable after initial blood transfusion. She was started on Protonix. Potassium and magnesium were appropriately replaced while inpatient.     Unresolved issues requiring follow up (w/ labs or studies): Follow-up BMP next week for potassium levels     Consults:   CONSULT TO SOCIAL WORK CONSULT TO GASTROENTEROLOGY CONSULT TO SOCIAL WORK CONSULT LUNG HEALTH ADVISOR   Significant Diagnostic Studies:    Chest x-ray with the left lower lobe pneumonia  Covid 19 positive Hypokalemia Hypomagnesemia   Operations:  None    Wound care recs: None    Disposition:  Home with home health   Discharge Condition:  good   Discharge Medications:   Current Discharge Medication List   START taking these medications   Details cefdinir (OMNICEF) 300 mg capsule Take 1 Capsule by mouth Twice a day for 3 days. Qty: 6 Capsule, Refills: 0   Associated Diagnoses: Pneumonia of left lower lobe due to infectious organism   doxycycline monohydrate (MONODOX) 100 mg capsule Take 1 Capsule by mouth Twice a day for 3 days. Indications: pneumonia Qty: 6 Capsule, Refills: 0   Associated Diagnoses: Pneumonia of left lower lobe due to infectious organism   potassium chloride SA (KLOR-CON) 20 mEq tablet Take 1 Tablet by mouth Once Daily for 3 days. Qty: 3 Tablet, Refills: 0   Associated Diagnoses: Hypokalemia   pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Once Daily for 30 days. Qty: 30 Tablet, Refills: 0   Associated Diagnoses: Gastroesophageal reflux disease with esophagitis, unspecified whether hemorrhage     CONTINUE these medications which have CHANGED   Details magnesium chloride (SLOW-MAG) 71.5 mg DR tablet Take 2 Tabs by mouth Twice a day for 30 days. Qty: 120 Tablet, Refills: 0   Associated Diagnoses: Hypomagnesemia     CONTINUE these medications which have NOT CHANGED   Details cyanocobalamin-salcaprozat sod 1,000 mcg Tab Take  by mouth.   levocetirizine (XYZAL) 5 mg tablet Take 5 mg by mouth Once Daily.   ergocalciferol (VITAMIN D2) 50,000 unit CAPSULE Take 1 Capsule by mouth Every week. Qty: 12 Capsule, Refills: 3   Associated Diagnoses: Vitamin D deficiency   levothyroxine (SYNTHROID) 50 mcg tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Nontoxic diffuse goiter   rosuvastatin (CRESTOR) 40 mg tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Mixed hyperlipidemia   clopidogreL (PLAVIX) 75 mg tablet Take 1 Tablet by mouth Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Coronary artery disease involving native coronary artery of native heart without angina pectoris   metoprolol (LOPRESSOR) 25 mg tablet Take 75 mg by mouth Twice a day.   amitriptyline (ELAVIL) 50 mg tablet Take 1 Tab by mouth Daily.