Age: 89.0
Sex: F
Vaccine: COVID19
Symptoms: Atrial fibrillation, COVID-19, Chronic kidney disease, Femur fracture, Hip fracture
Clinical narrative: Attestation signed by (M.D.) at 12/4/2023  8:19 AM   I have reviewed and verified the content of this Discharge Summary. The Discharge Summary accurately reflects the outcome of the patient?s hospitalization and/or treatment, the disposition of the patient, and the patient?s final diagnosis. I have verified that the Discharge Summary also provides for appropriate follow-up care to facilitate proper continuity of care.    Date of Admission: 11/27/2023   Date of Discharge: 12/2/2023    Issues to be Addressed at Follow-up: Wound check, pain management and activity level    Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 10/31/2023 to 12/1/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) LEFT FEMUR INTERTROCHANTERIC FX   ? ANTICOAGULATION MONITORING, INR SPECIAL RANGE       Indication: atrial fibrillation Start date: 3-12-12 Goal INR: 1.8-2.8 (new INR goal 1.8-2.8 per MD 5/14/13 due to recurrent bld shot eyes per Dr.)  Duration of therapy: indefinite    Anticoagulation Services       ? CKD STAGE 3B (GFR 30-44)   ? HYPERLIPIDEMIA   ? HTN (HYPERTENSION)       RESISTANT HYPERTENSION Normal ECHO 10/2010, normal renin/aldo. Felodipine swelling Clonidine sedation and dry mouth. Home bp monitor Consider prazosin/hytrin   ? COVID-19 DISEASE   ? SUBACUTE ENDOCARDITIS   ? ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  SNF   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 92 Y female who was admitted to the hospital for left femur fracture and underwent a left trochanteric femoral nail by Dr. on 11/29/23.  Patient post-operatively was ambulating with the use of a walker, anticoagulated back on Warfarin, received physical therapy and was prepared for discharge.   Primary Procedures:  Procedure(s): HIP FRACTURE CEPHALOMEDULLARY NAIL INSERTION   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Left hip fracture    Complications: none  Current Facility-Administered Medications Medication Dose Route ? PERI-COLACE/SENOKOT-S 1 tablet (Sennosides-Docusate Sod)  1 tablet Oral ? Polyethylene Glycol 3350 Packet 17 g (MIRALAX/GLYCOLAX)  17 g Oral ? Warfarin Tab 2.5 mg  2.5 mg Oral ? hydrALAZINE Tab 100 mg (APRESOLINE)  100 mg Oral ? Labetalol IV Syg 10 mg  10 mg intraVENOUS ? traZODone Tab 25 mg (DESYREL)  25 mg Oral ? Melatonin Tab 3 mg (MELATIN)  3 mg Oral ? Chlorhexidine Gluconate Oral Soln 15 mL (PERIDEX)  15 mL Oral ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS ? Ondansetron (PF) Inj 4 mg (ZOFRAN)  4 mg intraVENOUS ? oxyCODONE IR Tab 2.5 mg (ROXICODONE)  2.5 mg Oral ? HYDROmorphone Inj Syg 0.1 mg (DILAUDID)  0.1 mg intraVENOUS ? oxyCODONE IR Tab 5 mg (ROXICODONE)  5 mg Oral ? HYDROmorphone Inj Syg 0.2 mg (DILAUDID)  0.2 mg intraVENOUS ? Warfarin Per Protocol  1 Each Oral ? Amoxicillin Cap 500 mg  500 mg Oral ? dilTIAZem 24hr ER Cap 120 mg (CARDIZEM CD)  120 mg Oral ? Isosorbide Mononitrate 24hr SR Tab 30 mg  30 mg Oral ? Losartan Tab 50 mg (COZAAR)  50 mg Oral ? Metoprolol Tartrate Tab 100 mg (LOPRESSOR)  100 mg Oral ? Lidocaine 10 mg/mL (1 %) Inj 1 mg (Xylocaine)  0.1 mL Intradermal ? Flu Vaccine QS 2023-24 (65 yrs up) PF IM Syg 0.7 mL (FLUZONE HIGHDOSE QUAD)  1 Each intraMUSCULAR ? Melatonin Tab 3 mg (MELATIN)  3 mg Oral   Or ? Melatonin Tab 3 mg (MELATIN)  3 mg Nasogastric ? Famotidine Tablet 20 mg (PEPCID)  20 mg Oral ? Pharmacy Renal Monitoring  1 Each Miscell. (Med.Supl.;Non-Drugs)       Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. ORTHOPEDIC MEDICINE - INITIAL INPATIENT CONSULTATION. ORTHOPEDIC MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code      Cosigned by: (M.D.) at 12/4/2023  8:19 AM  Note Details  Author (P.A.-C) File Time 12/4/2023  8:19 AM Author Type PHYSICIAN ASSISTANT (P.A.) Status Signed Last Editor (P.A.-C) Specialty GENERAL, OTHER  Admit Date 11/27/2023  ED to Hosp-Admission (Discharged) on 11/27/2023  ED to Hosp-Admission (Discharged) on 11/27/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   SmartForms:   STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  FEMUR INTRAMEDULLARY ROD From 11/28/2023 to 11/28/2023 HIP FRACTURE CEPHALOMEDU From 11/28/2023 to 12/2/2023  Hospital Problem List   ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE  LEFT FEMUR INTERTROCHANTERIC FX  SUBACUTE ENDOCARDITIS  COVID-19 DISEASE  ANTICOAGULATION MONITORING, INR SPECIAL RANGE  HTN (HYPERTENSION)  HYPERLIPIDEMIA  CKD STAGE 3B (GFR 30-44) Care Timeline  11/28   Admitted from ED 0202 11/29   HIP FRACTURE CEPHALOMEDULLARY NAIL INSERTION 12/02   Discharged 1540  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 12/2/2023) Medication List at Discharge   acetaminophen Oral  amoxicillin 500 mg Oral 2 TIMES A DAY  calcium carbonate 200 mg calcium (500 mg) Chew 2 to 4 tablets by mouth as needed for stomach pain  diltiazem HCl 120 mg Oral DAILY  hydralazine HCl 100 mg Oral 3 TIMES A DAY WITH MEALS  isosorbide mononitrate 30 mg Oral DAILY  losartan potassium 50 mg Oral DAILY  metoprolol tartrate 100 mg Oral 2 TIMES A DAY  oxycodone HCl 5 mg Take one-half tablet by mouth every 6 hours as needed for moderate pain (take one whole tablet orally every 6 hour as needed for severe pain)  sennosides/docusate sodium 8.6-50 mg 1 tablet Oral 2 TIMES A DAY, Hold for diarrhea  warfarin sodium 2.5 mg Take by mouth as directed by Anticoagulation clinic