Age: 90.0
Sex: F
Vaccine: COVID19
Symptoms: Blood culture, Bradycardia, COVID-19, Cardiomyopathy, Chronic kidney disease
Clinical narrative: Date of Admission:  9/11/2023   Date of Discharge: 9/18/2023    Issues to be Addressed at Follow-up: Labs none Radiology none Appointments   Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Sep 25, 2023  9:30 AM PDT Eye procedure OPHTHALMOLOGY   OPHTHALMOLOGY         Pending Study Results at Discharge: Labs   Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/16/2023  6:43 AM BLOOD CULTURE Preliminary BLOOD   9/16/2023  6:37 AM BLOOD CULTURE 2 Preliminary BLOOD     Radiology none   Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? LONG TERM NON WARFARIN ORAL ANTICOAGULANT THERAPY       apixaban (Eliquis) 2.5mg BID Indications:  Atrial fibrillation Expected end of therapy date: lifelong (provider to reassess periodically)  Considerations: remote h/o GI bleeding (2004)       Periop Guideline Reference:   Go to Clinical Library ==>  Search: Anticoagulation Management - Perioperative- Anticoagulation Services Guideline       ? HTN (HYPERTENSION)   ? AORTIC VALVE STENOSIS   ? CKD STAGE 3A (GFR 45-59)   ? AGE-RELATED ATROPHY OF BRAIN   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA       Nonobstructive CAD on cath 4/2019   ? CARDIAC CATHETERIZATION NEGATIVE FOR SIGNIFICANT CORONARY ARTERY DISEASE       CCL 4/24/2019 Rt dom, LM:0%, LAD: <10% prox and mid 30%, CIRC: <10%, RCA: <10% LVEDP 23mmHg Aggressive medical management and risk factor modification.   Anticoagulation with heparin can be restarted at 7:00 pm if there is no bleeding complication.   LEFT VENTRICULAR EJECTION FRACTION Date Value Ref Range Status 04/24/2019 35 % Final           ? ATRIAL FIBRILLATION, UNSPECIFIED   ? BILAT GLAUCOMA SUSPECT   ? ASTHMA, UNSPECIFIED   ? AORTIC VALVE REGURGITATION   ? HYPERLIPIDEMIA     Resolved Hospital Problems   Diagnosis Date Resolved ? RECURRENT UTI 09/18/2023     Discharge Disposition:  Skilled Nursing Facility   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course with Narrative: 92 Y female with Afib CAD FHpEF, h/o CVA 2016, dementia, HTN, HLD, presented with COVID-19, UTI. She was treated with ceftriaxone and remdesivir. Never was hypoxic, so no dexamethasone indicated. Also noted to have dysphagia and high risk for aspiration, and was evaluated by speech therapy who recommended pureed diet. During hospitalization was noted to have bradycardia with up to 2 second pauses--family was against any surgical intervention including pacemaker. On 9/18/2023 Pt was evaluated and deemed stable for discharge to SNF.    Problem List and Treatment Plan: 1. COVID-19: Completed treatment with remdesivir. De-isolate after 9/20.  2. Dysphagia: continue soft, bite sized diet, medications with purees.  3. Atrial fibrillation: Continue elliquis. Avoid beta blocker given bradycardia 4. Bradycardia: pt with asymptomatic bradycardia with pauses up to 2 seconds. Avoid beta blockade. Pacermaker is not aligned with goals of care.  5. Coronary artery disease, cardiomyopathy, HFpEF: Continue statin. No need for diuretic therapy at this time. Not on ASA given anticoagulation on Elliquis.  6. HTN: Continue amlodipine 7. Asthma: Albuterol MDI prn 8. CKD3: avoid nephrotoxins 9. Glaucoma: continue latanoprost and dorzolamide eye drops as prescribed 10. Deconditioning: physical therapy     SNF Care: 1. Reason for SNF placement: Physical therapy 2. Expected SNF goals: Patient will be supervision with bed mobility Patient will be supervision with sit to stands with front wheel walker Patient will be supervision with ambulation of 50 feet with front wheel walker 3. Condition prior to discharge: Stable 4. Home/Social Situation: Supportive family   Primary Procedures:  None   Secondary Procedures: None   Complications: none   Consults:    Smoker: No.   Code Status at Time of Discharge: DNR/DNI     Subjective 9/18/2023: Feels well. Had some mild chest pain this morning with deep breathing which has resolved.    Physical Exam 9/18/2023 : BP 124/66  | Pulse 63  | Temp 98.2 °F (36.8 °C)  | Resp 18  | Wt 55.8 kg (123 lb 0.3 oz)  | SpO2 100%  | BMI 24.03 kg/m²   General appearance -  alert, elderly and frail, nontoxic appearing, and in no distress  Mental status - alert, oriented x3 Head - Normocephalic, atraumatic. Eyes - EOMI Neck - supple Respiratory - CTA, no wheezes, rales or rhonchi, symmetric air entry Cardiovascular -  RRR, normal S1, S2, no murmurs, rubs, or gallops Abdomen - soft, nontender, nondistended, no masses or organomegaly Extremities - No lower extremity edema  Neuro - nonfocal, speech intact   M.D. (she/her/hers) 12:35 PM    Pt discussed with Dr.               Note Details  Author   (M.D.) File Time 9/18/2023 12:37 PM Author Type PHYSICIAN, RESIDENT Status Cosign Needed Last Editor  (M.D.) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 9/11/2023  ED to Hosp-Admission (Current) on 9/11/2023  ED to Hosp-Admission (Current) on 9/11/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HYPERLIPIDEMIA  ASTHMA, UNSPECIFIED  ATRIAL FIBRILLATION, UNSPECIFIED  CAD (CORONARY ARTERY DISEASE) WO ANGINA  CKD STAGE 3A (GFR 45-59)  COVID-19 DISEASE  AORTIC VALVE REGURGITATION  BILAT GLAUCOMA SUSPECT  CARDIAC CATHETERIZATION NEGATIVE FOR SIGNIFICANT CORONARY ARTERY DISEASE  AGE-RELATED ATROPHY OF BRAIN  RECURRENT UTI Resolved  LONG TERM NON WARFARIN ORAL ANTICOAGULANT THERAPY  HTN (HYPERTENSION)  AORTIC VALVE STENOSIS Care Timeline  09/11   Admitted from ED 2143  Discharge   SNF Orders (Printed 9/18/2023) Medication List Given To Patient   acetaminophen   500 mg Tab, Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  500 mg Tab, Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED  amlodipine besylate 5 mg Oral DAILY  apixaban 2.5 mg Oral 2 TIMES A DAY  benzonatate 100 mg Oral 3 TIMES A DAY AS NEEDED  calcium carbonate/vitamin D3 600-125 mg-unit 1 tablet Oral DAILY  capsaicin 0.075 % Apply to affected area(s) 3 to 4 times a day. Unless treating hands, wash hands thoroughly with soap and water immediately after use  cholecalciferol (vitamin D3) 125 mcg (5,000 unit) 1 tablet Oral DAILY  diclofenac sodium 1 % Apply 4 Grams to affected area(s) 2 times a day as needed for knee pain  Patient not taking:  Reported on 9/11/2023  dorzolamide HCl 2 % Instill one drop in your left eye twice a day.  estradiol 0.01 % (0.1 mg/gram) Insert 0.5 grams vaginally 3 times a week at bedtime  hypromellose 0.3 % 1 Drop Ophthalmic  AS NEEDED  lanolin,anhydrous Topical 2 TIMES A DAY AS NEEDED  latanoprost 0.005 % 1 Drop Both eyes EVERY BEDTIME, for glaucoma. Refrigerate unopened bottles. Once opened, may store at room temperature for up to 6 weeks  lidocaine   4 % Ptmd patch, APPLY 1 PATCH TO THE AFFECTED AREA(S) EVERY 8 TO 12 HOURS  5 % Crea, Apply to affected area(s) 3 to 4 times a day as needed for pain  4 % Ptmd patch, Apply 1 patch to the affected area(s) every 8 hours  lovastatin 40 mg Take 2 tablets orally daily with evening meal for cholesterol.  multivit,calc,mins/iron/folic 1 tablet Oral DAILY  pt in house