Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Blood urea normal, Bronchiectasis, COVID-19, Carbon dioxide decreased, Chronic respiratory failure
Clinical narrative: Date of Admission Admit Date: Jul-30-2022  Date of Discharge Date of discharge Aug-01-2022  Allergies No Known Drug Allergies - Not Specified  Chief Complaint Weakness and nausea  Final Diagnoses Diarrhea  Procedure(s) Performed None  Lab Results Aug-01-2022 0529 Point Of Care GLUSTX  86 Aug-01-2022 0525 Chemistry GLUCOSE  86BUN  10CREAT  0.8MDRD GFR  94NA  138K  3.3CL  105CALCIUM  8.0ALK PHOS  84CO2  22.9AST  238ALT  569AST/ALT  0.4TL PROT  5.2ALBUMIN  1.9TBILI  0.4DBILI  0.1OSMO  274.0ANION GP  13.4BUN/CRE  12.5MAGNESIU  1.6 Aug-01-2022 0525 Hematology WBC  4.7RBC  4.13HGB  10.6HCT  32.2MCV  78.0MCH  25.7MCHC  32.9RDW  16.9RDWSD  47.2PLT  172MPV  9.2AUTONEU%  75.5AUTOLYM%  11.8AUTOMON%  7.6AUTOEOS%  3.2AUTOBAS%  0.2AUTONEU#  3.6AUTOLYM#  0.6AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.08IG%  1.7 Jul-31-2022 2021 Point Of Care GLUSTX  97 Jul-31-2022 1643 Point Of Care GLUSTX  109 Imaging Results MEDICAL CENTER IMAGING REPORT Diagnostic radiology,  Patient Name: Date of Exam: 7/30/2022 DOB: Gender: M Medical Record Number:  Accession Number:  Ordering Physician: DO Exam Description: CT ABD/PEL W/O IV CONTRAST RADIOLOGY INTERPRETATION PATIENT NAME:  DATE OF BIRTH:  RAD NUMBER:  PHYSICIAN do DATE OF EXAM Jul 30, 2022 11:56:23 AM CDT PROCEDURES CT - Abdomen and Pelvis WO HISTORY Prior sent. Weakness, + COVID, nausea, vomiting, diarrhea, elevated labs. IV CONTRAST (if appl) Without Exam: CT Abdomen and Pelvis Without IV Contrast Comparison: 02/06/2022 Findings: Posterior RIGHT lower lobe strandy atelectasis. Posterior bilateral lower lobe bronchiectasis and inflammatory airway thickening The liver density is homogeneous. No biliary abnormalities. The gallbladder is surgically absent. The spleen is normal in size. No pancreatic ductal dilatation. No hydronephrosis. There are bilateral renal upper pole simple cortical cysts. A 9 mm nonobstructing calculus is located in the posterior aspect of the RIGHT kidney with smaller adjacent 2 mm calculus. No ureteral obstruction. The ureters are completely visualized. Normal bowel caliber. No secondary sign of acute appendicitis. The appendix is 8 mm in diameter No free fluid/free air. No vascular abnormalities. The urinary bladder is decompressed by a Foley catheter. No suspicious skeletal lesions. Impression : 1. No hydronephrosis. There is mild bilateral perirenal fat stranding Page 1 of 2 MEDICAL CENTER NAME:   due to pressure backflow versus possible urinary tract infection. A 9 mm nonobstructing calculus is located in the RIGHT kidney.. 2. Subcutaneous edema and swelling in the RIGHT flank overlying the greater trochanter may represent contusion. 3. No signs of inflammatory bowel. 4. A 4 cm hiatal hernia is unchanged 5. Posterior RIGHT lower lobe consolidation has markedly decreased in size when compared to the previous exam. Inflammatory thickening of posterior bilateral lower lobe large airways is also improved Electronically signed on Jul 30, 2022 12:49:20 PM CDT by: MD Board of Radiology The above study was officially reviewed, dictated, and signed by a radiologist from Radiology (teleradiology company). It has then been proxy signed by an associated at Radiology. The below radiology associate assignment and electronic signature (proxy signature) only represents completion of the electronic process. The signature does not represent a review or interpretation of any radiology image(s) that were dictated in the report. DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY:  MD DICTATED DATE AND TIME: 7/30/2022 1:01 PM CDT  Functional Status* Impaired mobility, Activity of daily living - Needs assistance, Visual impairment  Mental Status* Normal Cognition  Social History tobacco use Former Smoker, 5 Packs Per Day, Smoking Cessation Not Applicable  alcohol use Liquor, Former  drug use No Known Use  marital status Unknown  Health Concerns Diarrhea  Former Smoker, 5 Packs Per Day  Liquor, Former  Father Deceased Chronic cerebrovascular accident @ 89  Father Deceased Myocardial infarction @ 69  Mother Deceased Malignant tumor of ovary @ 68  Sister Deceased Malignant tumor of pancreas @ 62  Sister Deceased Deep venous thrombosis @ 73  Sister Deceased Complicated appendicitis @ 10  Sister Deceased Anemia @ 10 months  Vital Signs Aug-01-2022 0400 HR 61 RR 20 BP   123 / 58 O2Sat 97 Aug-01-2022 0001 HR 60 RR 18 BP   106 /     48  O2Sat 99 Jul-31-2022 2000 T 98.9 Jul-31-2022 1553 T 98.9 PHYSICAL EXAM Constitutional: Patient appears stated age, chronically ill, and is in no acute distress at this time. He is lying in the hospital bed and appears chronically debilitated.  Cardiovascular: Regular rate and rhythm without murmur, gallop, or rub. Mild edema present in the lower extremities. Radial and dorsal pedal pulses intact 2+ bilaterally. Some swelling in the bilateral hands.  Respiratory: Lungs clear to auscultation bilaterally, no wheezing, no rhonchi, no rales. No accessory muscle use, no respiratory distress. Patient is currently on his baseline 3L with saturations consistently above 90%.  Gastrointestinal: Abdomen soft, non-tender. No rebound or guarding. No distension. No ascites. No organomegaly.  Genitourinary: No suprapubic tenderness to palpation. Foley catheter in place draining blood tinged urine. Catheter replaced with some difficulty. POCUS ultrasound of the bladder shows that the bulb and catheter are in the bladder.  Musculoskeletal: Tenderness to palpation of the right lateral neck. Paraspinal muscular hypertrophy right greater than left. Evidence of left shoulder arthroplasty vs other.  Psychiatric: Patient responds appropriately to questions and displays normal affect. Insight into disease process limited. Care goals not congruent with current status or effort. Patient with some grief over his deceased wife, now about 13 months past and 51 years of marraige.  Hospital Course Patient is a 74 yo male who presented to the ED with complaint of weakness and was placed in observation due to elevated LFT's. He has a past medical history is significant for type 2 diabetes mellitus, debility, coronary artery disease, and chronic indwelling foley catheter. The patient had recently been hospitalized at hospital due to septic shock from an UTI associated with his chronic indwelling foley catheter. Since that time he had been on multiple hepatotoxic medications to help treat the infection as well as prevent further infections. On admission he was found to be COVID-19 positive but was quickly at his baseline oxygen needs. CT showed resolving pneumonia. Patient was noted to have an ejection fraction of 20-25% from an echo performed 9/21. His liver enzymes were elevated on admission and the following meds were held: Atorvastatin, Ciprofloxacin, fluconazole, Pantoprazole, methanimine, Acetamenophen, Hydrocodone-Acetamenophen, Orgovyx, Pregabalin. Acetaminophen level when drawn was zero. The enzymes were noted to be improving by the second day. His sacral ulcers have been treated with mepilex. Diabetes was treated with home dose basal, but his needs were less than expected. On discharge he will be decreased to 45 units daily without change to his mealtime. Patient's inflammatory markers were trended down. On 8/1/22 patient was found to have some hematuria and clotting. Patient's foley was exchanged and minimal irrigation resulted in clear urine. His family has been urged to keep appointments with Dr. and Dr. . We have also sent referral information to infectious disease, to help manage patient's chronic antibiotics.  Condition at Discharge Stable  Discharge Medications ARIPiprazole Tablet 10 MG 10 MG ORALLY ONCE A DAY Aspirin Adult Low Dose Oral Tablet Delayed Release 81 MG 81 MG ORALLY ONCE A DAY Atorvastatin Calcium Tablet 80 MG 80 MG ORALLY ONCE A DAY Brimonidine 0.1% BID 1 DRP BOTH EYES TWICE DAILY buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG 150 MG ORALLY TWICE DAILY busPIRone HCl Tablet 5 MG 5 MG ORALLY TWICE DAILY Calcium 1000 + D Oral Tablet 1000-800 MG-UNIT 1 TAB ORALLY ONCE A DAY Ciprofloxacin HCl Tablet 500 MG 500 MG ORALLY TWICE DAILY Clopidogrel Bisulfate Tablet 75 MG 75 MG ORALLY ONCE A DAY Combigan Ophthalmic Solution 0.2-0.5 % 1 DRP OPHTHALMIC TWICE DAILY Entresto Tablet 49-51 MG 1 TAB ORALLY ONCE A DAY Fish Oil Burp-Less Oral Capsule 1200 MG 1200 MG ORALLY TWICE DAILY FLUoxetine HCl Capsule 40 MG 40 MG ORALLY ONCE A DAY HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML 13 UNT SUBCUTANEOUSLY 3 TIMES A DAY BEFORE MEALS Latanoprost Ophthalmic Solution 0.005 % 1 DRP OPHTHALMIC ONCE A DAY LIDOCAINE PAIN RELIEF 4 % 1 PAT TRANSDERMAL ON IN AM AND OFF AT HS (ePrescribed by DO on Aug-01-2022 1325) Methenamine Hippurate Oral Tablet 1 GM 1 GM ORALLY TWICE DAILY MICONAZOLE NITRATE POWDER 2 % 1 APP TOPICAL TWICE DAILY Multivitamin Adult Oral Tablet 1 TAB ORALLY ONCE A DAY Orgovyx Oral Tablet 120 MG 120 MG ORALLY ONCE A DAY Pantoprazole Sodium Tablet Delayed Release 40 MG 40 MG ORALLY ONCE A DAY Pregabalin Capsule 75 MG 75 MG ORALLY TWICE DAILY Ramelteon Oral Tablet 8 MG 8 MG ORALLY AT BEDTIME AS NEEDED for INSOMNIA Refresh Plus Ophthalmic Solution 0.5 % 1 DRP OPHTHALMIC TWICE DAILY Spiriva HandiHaler Capsule 18 MCG 1 CAP INHALATION ONCE A DAY Toujeo SoloStar Subcutaneous Solution Pen-injector 300 UNIT/ML 45 UNT SUBCUTANEOUSLY ONCE A DAY Vitamin C Oral Tablet 1000 MG 1000 MG ORALLY ONCE A DAY ZINC OXIDE 20% TOPICAL 60 GM 1 APP TOPICAL ONCE A DAY ZyrTEC Allergy Oral Capsule 10 MG 10 MG ORALLY ONCE A DAY Discharge Disposition Discharge to home with home health  Plan Assessments: -Transaminitis likely secondary hepatocellular injury secondary to hepatotoxic medications, improving -Chronic indwelling foley catheter with colonization of yeast and bacteria with recent urinary tract infection causing septic shock 1 week prior to admission, treated with antibiotics and fluconazole. -Hematuria, started on 8/1/22, possibly residual clots which are now resolving. Foley exchanged 8/1/22. -COVID-19 infection without worsening hypoxia from baseline -Chronic hypoxic respiratory failure, likely secondary to a combination of COPD and heart failure with reduced ejection fraction with pulmonary artery hypertension, 3L NC baseline -Debility secondary to compounding chronic conditions -Sacral ulcers, numerous stage I and one large unstagable - Pressure ulcers Stage I bilateral heels and on back -Chronic kidney disease stage 3a/3b, likely diabetic nephropathy and hypertensive nephrosclerosis with HFrEF -Chronic heart failure with reduced ejection fraction, EF 20-25% on echocardiogram September 2021, without acute decompensation -Chronic obstructive lung disease, without exacerbation -Type II diabetes mellitus, on exogenous insulin therapy with associated diabetic neuropathy and nephropathy, unknown control hemoglobin A1c pending -Peripheral venous insufficiency, CEAP classification C6,ES,AS,PN -Nonhealing diabetic ulcers, longstanding -Obstructive sleep apnea, on BiPAP -Mild mitral regurgitation, per echocardiogram 09/03/2020 -Mild tricuspid regurgitation, per echocardiogram 09/03/2020 -Mild to moderate pulmonic regurgitation, per echocardiogram 09/03/2020 -Pulmonary artery hypertension -History of ischemic stroke, per patient history -Obesity class I, BMI 32.075 -Gastroesophageal reflux disease -History of fibromyositis -Major depressive disorder -Mixed hyperlipidemia, per patient history -Polymyalgia rheumatica, per patient history -Progressive supranuclear ophthalmoplegia, per patient history -Chronic iron-deficiency anemia -Benign prostatic hypertrophy -History of ventricular arrhythmia, pacemaker defibrillator in situ -History of prostate cancer, per patient history, currently on antihormonal therapy -Polypharmacy -Nephrolithiasis seen on CT 7/30/22 -R sided Atelectasis seen on CT 7/30/22 -Yeast Infection in Groin/Scrotal area, stable -Hypomagnesemia, improved  Plan: Patient has been deemed stable and in conjunction with family and patient's wishes we are discharging home with home health.    Patient has been resolving during his stay. His liver enzymes have improved greatly and his inflammatory markers are also down. He requests to go home.  Patient should keep his appointment with Dr. (8/2/22) for hospital follow up. I have voiced this to the family.  Follow up for hematuria with Dr. on 8/16/22.   Patient is to complete his antibiotics as prescribed until complete. Patient will be called by facilities should they accept my referral.  Patient has been connected to services through data. He will have nursing assistance, PT and OT services.   Patient's medications have been reconciled with resuming most of his medications. I have suggested holding acetaminophen products until his liver derangements are fully resolved. I have sent 10 lidocane patches for pain during this timeframe.  Plan of care was discussed with Dr. and staff via phone and agreed to. Patient also agrees with plan of care.  DO  Primary Care Provider DO  Electronically signed by RESIDENT on Aug-01-2022 1412