Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac device reprogramming, Cardiac pacemaker evaluation, Cardiomegaly, Carotid arteriosclerosis, Carotid artery stenosis
Clinical narrative: Date of Service Nov-07-2022 0850  Date of Admission Admit Date: Oct-28-2022  Date of Discharge Date of discharge Nov-07-2022  Allergies Metformin HCl - Not Specified  Sotalol - Not Specified  Chief Complaint Nausea and Vomiting, Elevated blood pressures, Acute on Chronic Renal injury  Final Diagnoses Sick sinus syndrome  Urinary tract infectious disease  Disorder of kidney due to diabetes mellitus  Chronic kidney disease stage 4  Hypertensive urgency  Procedure(s) Performed performed Nov-07-2022  Interrogation of cardiac pacemaker  Performed by DO Procedure Start Date - Nov-07-2022 07:37 Lab Results Nov-07-2022 0608 Hematology WBC  11.3RBC  3.12HGB  8.7HCT  27.5MCV  88.1MCH  27.9MCHC  31.6RDW  13.2RDWSD  41.6PLT  287MPV  11.6AUTONEU%  61.5AUTOLYM%  25.0AUTOMON%  6.7AUTOEOS%  6.0AUTOBAS%  0.4AUTONEU#  7.0AUTOLYM#  2.8AUTOMON#  0.8AUTOBAS#  0.1AUTOEOS#  0.7NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.05IG%  0.4 Nov-07-2022 0608 Chemistry GLUCOSE  116BUN  52CREAT  4.1MDRD GFR  11NA  139K  4.3CL  101CALCIUM  8.0CO2  25.7OSMO  292.6ANION GP  16.6BUN/CRE  12.7 Nov-07-2022 0551 Point Of Care  Nov-06-2022 2054 Point Of Care  Nov-06-2022 1634 Point Of Care  Nov-06-2022 1149 Point Of Care  Nov-06-2022 0640 Serology PROCALC  <0.05 Nov-06-2022 0640 Hematology WBC  8.6RBC  3.01HGB  8.3HCT  26.2MCV  87.0MCH  27.6MCHC  31.7RDW  13.0RDWSD  41.3PLT  266MPV  12.1AUTONEU%  53.1AUTOLYM%  31.9AUTOMON%  7.3AUTOEOS%  6.9AUTOBAS%  0.3AUTONEU#  4.6AUTOLYM#  2.7AUTOMON#  0.6AUTOBAS#  0.0AUTOEOS#  0.6NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.04IG%  0.5 Nov-06-2022 0640 Chemistry GLUCOSE  138BUN  52CREAT  4.3MDRD GFR  10NA  137K  3.4CL  99CALCIUM  7.9CO2  26.0OSMO  290.1ANION GP  15.4BUN/CRE  12.1 Nov-02-2022 1455 Urinalysis Department SPECGRAV  1.015U-PH  6.0LEUCOCYT  ModerateNITRITES  NegativePROTEIN  100GLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  LargeCOLOR  AmberCLARITY  CloudyMICROSCP  YCULTURE  YWBC  40-60RBC  80-100SQUAM EP  NoneBACTERIA  3+MUCUS  None Nov-02-2022 1455 Microbiology C UR  Enterobacter cloacae complex Nov-02-2022 1455 Chemistry BUN  61CREAT  4.8CREA-U  61FEUREA  44.63UUN  346 Nov-02-2022 0445 Hematology WBC  8.7RBC  3.13HGB  8.7HCT  27.0MCV  86.3MCH  27.8MCHC  32.2RDW  12.9RDWSD  40.4PLT  293MPV  11.7AUTONEU%  62.9AUTOLYM%  25.1AUTOMON%  5.6AUTOEOS%  5.6AUTOBAS%  0.5AUTONEU#  5.5AUTOLYM#  2.2AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.5NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.03IG%  0.3 Nov-02-2022 0445 Chemistry GLUCOSE  121BUN  61CREAT  4.8MDRD GFR  9NA  139K  3.7CL  101CALCIUM  8.1CO2  25.0OSMO  296.0ANION GP  16.7BUN/CRE  12.7PHOSPHOR  4.9 Nov-01-2022 0510 Hematology WBC  8.2RBC  2.83HGB  8.0HCT  24.4MCV  86.2MCH  28.3MCHC  32.8RDW  12.6RDWSD  39.8PLT  257MPV  11.6AUTONEU%  56.0AUTOLYM%  31.3AUTOMON%  5.3AUTOEOS%  7.0AUTOBAS%  0.2AUTONEU#  4.6AUTOLYM#  2.6AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.6NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.02IG%  0.2 Nov-01-2022 0510 Chemistry GLUCOSE  110BUN  63CREAT  4.4MDRD GFR  10NA  136K  3.5CL  102CALCIUM  7.8CO2  25.9OSMO  290.6ANION GP  11.6BUN/CRE  14.3 Oct-31-2022 0500 Hematology WBC  8.2RBC  3.13HGB  8.7HCT  27.2MCV  86.9MCH  27.8MCHC  32.0RDW  12.7RDWSD  40.3PLT  253MPV  11.8AUTONEU%  55.4AUTOLYM%  30.8AUTOMON%  6.6AUTOEOS%  6.3AUTOBAS%  0.4AUTONEU#  4.5AUTOLYM#  2.5AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.5NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.04IG%  0.5 Oct-31-2022 0500 Chemistry GLUCOSE  110BUN  58CREAT  3.6MDRD GFR  12NA  136K  3.6CL  101CALCIUM  7.9CO2  25.9OSMO  288.8ANION GP  12.7BUN/CRE  16.1MAGNESIU  2.3 Oct-30-2022 1240 Chemistry HGBA1C  5.9MEAN GLU  133 Oct-30-2022 0508 Hematology WBC  6.3RBC  3.02HGB  8.4HCT  26.5MCV  87.7MCH  27.8MCHC  31.7RDW  12.7RDWSD  40.5PLT  235MPV  12.1AUTONEU%  44.3AUTOLYM%  41.9AUTOMON%  7.8AUTOEOS%  5.2AUTOBAS%  0.5AUTONEU#  2.8AUTOLYM#  2.6AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.3NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.02IG%  0.3 Oct-30-2022 0508 Chemistry GLUCOSE  96BUN  66CREAT  3.5MDRD GFR  13NA  135K  3.7CL  99CALCIUM  8.1CO2  24.9OSMO  289.0ANION GP  14.8BUN/CRE  18.9 Oct-29-2022 1757 Hematology WBC  7.7RBC  3.14HGB  8.9HCT  27.2MCV  86.6MCH  28.3MCHC  32.7RDW  12.7PLT  258MPV  11.8NRBC%  0.0 Oct-29-2022 1757 Coagulation PT  10.7INR  1.0 Imaging Results MEDICAL CENTER  IMAGING REPORT Diagnostic radiology Patient Name: Date of Exam: 11/02/2022 DOB: Gender: F  Ordering Physician:  Exam Description: MRI HEAD WO CON EXAM: MRI head without IV contrast INDICATION: Transient ischemic attack. Facial droop. COMPARISON: 5/2/2022 TECHNIQUE: Axial, coronal and sagittal MR images of the brain were acquired utilizing multiple pulse sequences without IV contrast. DISCUSSION: Diffusion weighted and apparent diffusion coefficient images show no evidence of acute ischemia. Multiple foci of FLAIR hyperintensity in the periventricular and subcortical white matter. There is no intracranial hemorrhage, mass or mass effect. The ventricles, basal ganglia, thalamus, brainstem and cerebellum are unremarkable. Well-defined T1 hypointense and mildly T2 hyperintense intraconal mass posteriorly on the right between the medial rectus muscle and optic nerve measuring 1.5 cm AP, 1.4 cm wide and 1.3 cm craniocaudad. Lateral displacement of the optic nerve. Bilaterally aphakia. Moderate mucosal thickening in the ethmoid, maxillary and sphenoid sinuses. Bilateral mastoid air cell fluid signal intensity. IMPRESSION: 1. No acute intracranial abnormality. 2. Mild periventricular and subcortical changes of chronic microangiopathy. 3. Unchanged intraconal mass posteromedially on the right. 4. Chronic sinusitis. 5. Benign mastoid effusions. This exam was interpreted on workstation DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 11/2/2022 4:12 PM CDT   --------------------------------------------- MEDICAL CENTER  IMAGING REPORT Diagnostic radiology  Patient Name: Date of Exam: 10/31/2022 DOB: Gender: F  Ordering Physician: RESIDENT Exam Description: US ABD RETRO (RENAL, AORTA,ETC) EXAM: Retroperitoneal ultrasound INDICATION: Right renal lesion; history of hematoma; prior renal biopsy TECHNIQUE: Retroperitoneal ultrasound was performed. COMPARISON: None. FINDINGS: The right kidney is 10.7 x 5.7 x 5.1 cm. An 1 cm cyst is present at the lower pole of the right kidney. No solid renal mass, renal calculus or hydronephrosis on this side. The left kidney is 7.8 x 4.6 x 4.0 cm. Indistinct renal cortex. No solid renal mass, renal calculus, or hydronephrosis on this side. The urinary bladder has an estimated volume of 80 mL at the time of this exam. Urinary bladder wall thickening may be related to nondistention. Ureteral jets not demonstrated during this exam. Indwelling Foley catheter noted. IMPRESSION: 1. No solid renal mass, renal calculus or hydronephrosis on either side. 2. Indistinct left renal cortex, nonspecific. Parenchymal disease is not excluded. 3. Urinary bladder wall thickening, likely related to nondistention. This exam was interpreted on workstation DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/31/2022 4:06 PM CDT   --------------------------------------------- MEDICAL CENTER  IMAGING REPORT Diagnostic radiology  Patient Name: Date of Exam: 10/30/2022 DOB: Gender: F  Ordering Physician: DO Exam Description: CT HEAD/BRAIN WO PATIENT NAME:  DATE OF BIRTH:  RAD NUMBER:  PHYSICIAN  DATE OF EXAM Oct 29, 2022 6:49:14 PM CDT PROCEDURES CT head without contrast (stroke alert) and CTA head HISTORY Facial droop; STROKE ALERT IV CONTRAST (if appl) With isovue 370 100 ml given EXAM: CT head TECHNIQUE: CT image acquisition of the brain without contrast. COMPARISON: 9/13/21. FINDINGS: No acute intracranial hemorrhage or midline shift. The ventricles and extra-axial CSF spaces are normal in size and configuration for age. Volume averaging artifact within the anterior-inferior left frontal lobe, axial image 13 of 32. Additional scattered low-density foci within the cerebral white matter. Soft tissue mass within the right posterior orbit, which appears circumscribed and is difficult to distinguish from the adjacent optic nerve. Imaged paranasal sinuses and mastoid air cells are clear. Bilateral paranasal sinus mucosal thickening. No acute calvarial findings. IMPRESSION: No acute intracranial hemorrhage. No CT evidence of large vascular territory infarct. Circumscribed right posterior orbital mass, slightly increased in size from prior, incompletely characterized. Recommend follow-up MRI orbits with IV Page 1 of 2 MEDICAL CENTER NAME:  contrast. This report was discussed with Dr. on Oct 29, 2022 17:59:00 CDT. EXAM: CT head angiogram COMPARISON: Same day CT head. TECHNIQUE: CT angiogram of the head was performed after IV administration of nonionic intravenous contrast. Imaging was acquired in the arterial phase. 3-D rotational reformats provided. FINDINGS: Anterior circulation: No large vessel occlusion or high-grade stenosis. Non-flow-limiting calcific plaques of the intracranial ICAs. No aneurysm visualized. Posterior circulation: Attenuated appearance of the proximal and mid basilar artery, with moderate stenosis. The basilar artery remains patent. The distal vertebral arteries are patent. The major branches of the PCAs are grossly patent. No aneurysm visualized. Brain: Refer to recently performed head CT. No abnormal intracranial enhancement. Other: Dural venous sinuses appear grossly patent. Redemonstrated right intraorbital mass. Bilateral paranasal sinus disease. No acute osseous findings. IMPRESSION: Moderate narrowing of the proximal and mid basilar artery, likely from atherosclerotic vascular disease. No additional stenosis or occlusion within the major intracranial arterial vasculature. Redemonstrated right intraorbital mass. Recommend follow-up MRI orbits. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/30/2022 10:27 AM CDT  --------------------------------------------- Medical Center Transthoracic Echocardiogram Report Patient Name: Gender: Female  Birth Date:  Study Date: 30-Oct-2022 Tech: Location:  Height(Cm): 160 Weight(Kg): 99.80 BSA: 2.11 Ref. Physician: Quality: Good Procedures: Echocardiogram complete with 2D, M-Mode, and Doppler examination. Indications: Cerebrovascular Accident. 2D/M Mode Doppler Measurement Value Normal Range Measurement Value Normal Range LVIDd (MM) 5.6 cm AV Area Vmax 2.7 cm2 LVIDs (MM) 3.3 cm AV Area VTI 2.7 cm2 IVSd (MM) 1.3 cm AV Peak PG 20.0 mmHg LVPWd (MM) 1.2 cm AV Mean PG 11.0 mmHg LA Dimen MM 3.0 cm MV E/A 0.6 LVOT Peak Vel 1.3 m/sec E/E` 9.6 Findings Left Ventricle: Normal left ventricular systolic function with LVEF >60%. Mild left ventricular hypertrophy ( measuring diameter 1.1cm - 1.3cm). Impaired relaxation (Grade I diastolic dysfunction). Left Atrium: Mild left atrial enlargement which is consistent with LA index volumes between 35 - 41 cm2. Mitral Valve: Mild mitral regurgitation. Aortic Valve: Aortic cusps appear mildly calcified. Trileaflet aortic valve. Trace aortic regurgitation. Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function. Right Atrium: Normal with RA size <40mm. Atrial Septum: Normal atrial septum. Agitated saline was injected intravenously for microbubble contrast study. No right to left shunt was identified. Tricuspid Valve: Normal appearance and function of the tricuspid valve with trace physiologic regurgitation. Normal right ventricular systolic pressure. Pulmonic Valve: Normal pulmonic valve appearance and function with trivial (physiologic) regurgitation. IVC: Normal inferior vena cava appearance and respiratory collapse. Aorta: Aortic root size is normal. Pericardium: Small pericardial effusion. No echocardiographic evidence to suggest pericardial tamponade. Thickened. Conclusions Normal left ventricular systolic function with LVEF >60%. Mild left ventricular hypertrophy ( measuring diameter 1.1cm - 1.3cm). Impaired relaxation (Grade I diastolic dysfunction). Mild left atrial enlargement which is consistent with LA index volumes between 35 - 41 cm2. Normal atrial septum. Agitated saline was injected intravenously for microbubble contrast study. No right to left shunt was identified. Mild mitral regurgitation. Small pericardial effusion. No echocardiographic evidence to suggest pericardial tamponade. Thickened. Aortic cusps appear mildly calcified. Trileaflet aortic valve. Trace aortic regurgitation. Electronically Signed By:   --------------------------------------------- MEDICAL CENTER  IMAGING REPORT Diagnostic radiology  Patient Name: Date of Exam: 10/29/2022 DOB:  Gender: F   Ordering Physician: DO Exam Description: CTA HEAD CIRCLE WIL PATIENT NAME:  DATE OF BIRTH:  RAD NUMBER:  PHYSICIAN  DATE OF EXAM Oct 29, 2022 6:49:14 PM CDT PROCEDURES CT head without contrast (stroke alert) and CTA head HISTORY Facial droop; STROKE ALERT IV CONTRAST (if appl) With isovue 370 100 ml given EXAM: CT head TECHNIQUE: CT image acquisition of the brain without contrast. COMPARISON: 9/13/21. FINDINGS: No acute intracranial hemorrhage or midline shift. The ventricles and extra-axial CSF spaces are normal in size and configuration for age. Volume averaging artifact within the anterior-inferior left frontal lobe, axial image 13 of 32. Additional scattered low-density foci within the cerebral white matter. Soft tissue mass within the right posterior orbit, which appears circumscribed and is difficult to distinguish from the adjacent optic nerve. Imaged paranasal sinuses and mastoid air cells are clear. Bilateral paranasal sinus mucosal thickening. No acute calvarial findings. IMPRESSION: No acute intracranial hemorrhage. No CT evidence of large vascular territory infarct. Circumscribed right posterior orbital mass, slightly increased in size from prior, incompletely characterized. Recommend follow-up MRI orbits with IV Page 1 of 2 MEDICAL CENTER NAME: contrast. This report was discussed with Dr. on Oct 29, 2022 17:59:00 CDT. EXAM: CT head angiogram COMPARISON: Same day CT head. TECHNIQUE: CT angiogram of the head was performed after IV administration of nonionic intravenous contrast. Imaging was acquired in the arterial phase. 3-D rotational reformats provided. FINDINGS: Anterior circulation: No large vessel occlusion or high-grade stenosis. Non-flow-limiting calcific plaques of the intracranial ICAs. No aneurysm visualized. Posterior circulation: Attenuated appearance of the proximal and mid basilar artery, with moderate stenosis. The basilar artery remains patent. The distal vertebral arteries are patent. The major branches of the PCAs are grossly patent. No aneurysm visualized. Brain: Refer to recently performed head CT. No abnormal intracranial enhancement. Other: Dural venous sinuses appear grossly patent. Redemonstrated right intraorbital mass. Bilateral paranasal sinus disease. No acute osseous findings. IMPRESSION: Moderate narrowing of the proximal and mid basilar artery, likely from atherosclerotic vascular disease. No additional stenosis or occlusion within the major intracranial arterial vasculature. Redemonstrated right intraorbital mass. Recommend follow-up MRI orbits. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/30/2022 10:27 AM CDT   --------------------------------------------- MEDICAL CENTER  IMAGING REPORT Diagnostic radiology  Patient Name: Date of Exam: 10/29/2022 DOB: Gender: F  Ordering Physician: DO Exam Description: CTA CAROTID PATIENT NAME:  DATE OF BIRTH:  RAD NUMBER: 304850 PHYSICIAN  DATE OF EXAM Oct 29, 2022 6:49:14 PM CDT PROCEDURES CT - Angio Neck HISTORY facial droop IV CONTRAST (if appl) With isovue 370 100 ml given EXAM: CT neck angiogram COMPARISON: None available. TECHNIQUE: CT angiogram of the neck was performed after IV administration of nonionic intravenous contrast. Imaging was acquired in the arterial phase. 3-D rotational reformats provided. FINDINGS: Origins of the aortic arch branch vessels are patent. Mild atherosclerotic plaque most notably involving the left subclavian artery origin. Prominent soft tissue and calcific plaque at the left carotid bifurcation, with approximately 50% narrowing . Calcified plaque with additional small soft tissue component along the lateral margin at the right carotid bifurcation, with minimal stenosis. The vertebral arteries are normal in course and caliber without significant stenosis. Scattered non-flow-limiting calcific plaques are noted bilaterally. Subcentimeter thyroid nodules. Partially imaged moderate size left pleural effusion. Coronary artery calcification. Bilateral paranasal sinus disease. A right orbital mass will be described in the report of the CTA head from the same day. Degenerative changes of the spine. IMPRESSION: 1. Bilateral carotid bifurcation plaques, with approximately 50% stenosis Page 1 of 2 MEDICAL CENTER NAME:  on the left. Prominent soft tissue components present, particularly on the left, which can be associated with high risk/vulnerable carotid plaques. 2. No evidence of carotid or vertebral artery dissection. 3. Partially imaged left pleural effusion. 4. Please see today's CTA head report for additional information. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/30/2022 10:19 AM CDT  --------------------------------------------- MEDICAL CENTER  IMAGING REPORT Diagnostic radiology  Patient Name: Date of Exam: 10/29/2022 DOB: Gender: F  Ordering Physician: RESIDENT Exam Description: STROKE PROTOCOL(CT HEAD WO) EXAM: STROKE PROTOCOL(CT HEAD WO) INDICATION: Stroke. Facial droop. TECHNIQUE: Axial CT images of the head obtained without intravenous contrast. Sagittal and coronal reconstructions provided and evaluated. One of the following dose optimization techniques was utilized in the performance of this exam: Automated exposure control; adjustment of the mA and/or kV according to the patient's size; or use of an iterative reconstruction technique. COMPARISON: Brain MRI 05/02/2022. FINDINGS: Mild changes of chronic small vessel ischemic disease. No midline shift or mass effect. No hydrocephalus. No intracranial hemorrhage. No extra-axial fluid. No CT evidence of an acute infarct. Right retro-orbital mass appears slightly larger than prior brain MRI. This could further be evaluated with orbit MRI. Moderate paranasal sinus mucosal thickening. Mastoid air cells are clear. A preliminary report was provided by Real Radiology at 5:53 p.m. on 10/29/2022. IMPRESSION: 1. No acute intracranial abnormalities. 2. Right retro-orbital mass appears slightly larger than prior brain MRI. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/31/2022 9:01 AM CDT   --------------------------------------------- MEDICAL CENTER  IMAGING REPORT Diagnostic radiology  Patient Name: Date of Exam: 10/28/2022 DOB: Gender: F  Ordering Physician: DO Exam Description: CH-ABDOMEN 1 VIEW DR Exam: CH-ABDOMEN 1 VIEW DR, 10/28/2022 11:54 AM CDT Indication: Abdominal pain and distention Comparison: Chest radiograph 6/9/2022 Technique: Supine views of the abdomen. Findings: Moderate gaseous distention of the cecum measuring up to 8 cm. Moderate colonic stool burden. Postsurgical changes in the left hemiabdomen. No pneumatosis or portal venous gas. No acute osseous abnormality. Advanced degenerative changes of the spine. Moderate degenerative changes of the hips. Partially visualized lower thorax. Small pleural effusion on the left. Cardiomegaly. Partially visualized pacemaker leads. Impression: 1. Moderate gaseous distention of the cecum measuring up to 8 cm. This is within the upper limits of normal. Consider CT if there is clinical concern for cecal volvulus. 2. Moderate colonic stool burden. 3. Cardiomegaly. 4. Small left pleural effusion. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: DO DICTATED DATE AND TIME: 10/28/2022 12:35 PM CDT  Functional Status* Visual impairment (Right sided blindness)  Mental Status* Normal Cognition  Social History tobacco use Never Smoked, Smoking Cessation Not Applicable  alcohol use No Known Use  drug use No Known Use  marital status Married  general comment Lives at home with husband, uses cane to walk  Health Concerns Sick sinus syndrome  Urinary tract infectious disease  Disorder of kidney due to diabetes mellitus  Chronic kidney disease stage 4  Hypertensive urgency  Father Deceased Myocardial infarction @ 55  Mother Deceased Cerebrovascular accident @ 50  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Nov-07-2022 0628 T 97.2 HR 60 RR 18 BP       152  / 64 O2Sat 96 Nov-07-2022 0320 T 97.9 HR 60 RR 20 BP       153  / 66 O2Sat 99 PHYSICAL EXAM CONSTITUTIONAL:  Patient appears comfortable and in no acute distress. She is bedside with her husband. CARDIOVASCULAR:  Heart has regular rate rhythm, pulses are 2/2 in the upper extremities, no edema noted RESPIRATORY:  Lungs clear to auscultation throughout and respiratory effort is non-labored GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive NEUROLOGICAL:  Patient is alert and generally oriented. Sensation is grossly intact PSYCHIATRIC:  Patient's mood is tearful with stress of chronic conditions, affect is appropriate. RASS of 0.  Consultations Dr., Cardiology Tele - Nephrology Tele - Neurology  Hospital Course Patient is a 71 year old female who presented to the ED with nausea, vomiting and diarrhea. She was admitted to the ICU for hypertensive urgency and was found to be COVID positive. She exhibited left facial droop and a code stroke called on 10/29/22. CT head and CTA head/neck ruled out acute intracranial pathology. Teleneurology consulted. MRI 11/3/22 negative for acute findings. Due to an indwelling pacemaker, patient required a cardiology consult to reprogram the pacemaker for MRI mode then reprogram, which was performed successfully. Telenephrology was consulted in the setting of resistant hypertension and persistent elevation of creatine and azotemia. Blood pressure remained high throughout patient's stay. Multiple medications were trialed. Management was difficult in setting of kidney injury. A renal ultrasound and urine metanephrines were sent to rule out possible secondary cause. Renal ultrasound showed some cortical thickening but no other abnormalities. Of note, patient had a renal biopsy on the 1st of August which was complicated by hematoma and 2 week hospital stay. Results of the biopsy showed diabetic nephropathy. Urine metanephrines are pending at time of writing. Blood pressure stabilized between systolic 130 and 170, and patient was deemed stable to transfer to Nursing Home with close follow up as detailed below. Our goal is that patient rehabilitate to home.  Condition at Discharge Stable  Discharge Medications ACETAMINOPHEN 650 MG ORALLY EVERY 4 HOURS AS NEEDED for FEVER OR MILD PAIN 1-3 ON PS amLODIPine BESYLATE 5 MG ORALLY DAILY AT BEDTIME (ePrescribed by SAMUELSON OLAF RESIDENT on Nov-07-2022 1014) ASPIRIN LOW DOSE 81 MG ORALLY ONCE A DAY ATORVASTATIN CALCIUM 80 MG ORALLY DAILY AT BEDTIME (ePrescribed by SAMUELSON OLAF RESIDENT on Nov-07-2022 1014) Carvedilol Oral Tablet 6.25 MG 6.25 MG ORALLY TWICE DAILY WITH MEALS CIPROFLOXACIN HCL 500 MG ORALLY ONCE A DAY clonazepam 1 mg tab 1 MG ORALLY DAILY AT BEDTIME cloNIDine HCL 0.2 MG/24HR 0.2 MG TRANSDERMAL EVERY WEEK (ePrescribed by SAMUELSON OLAF RESIDENT on Nov-07-2022 1014) diltiazem HCl 180 mg Tb24 180 MG ORALLY ONCE A DAY Eliquis Oral Tablet 5 MG 2.5 MG ORALLY TWICE DAILY FLUTICASONE PROPIONATE NASAL 50 MCG / SPRAY 2 SPR NASAL ONCE A DAY Glimepiride Oral Tablet 1 MG 1 MG ORALLY ONCE A DAY hydrALAZINE 50 MG ORALLY 3 TIMES A DAY (ePrescribed by SAMUELSON OLAF RESIDENT on Nov-07-2022 1014) Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 60 MG 60 MG ORALLY ONCE A DAY LOSARTAN POTASSIUM 25 MG ORALLY EVERY DAY BLOOD PRESSURE (ePrescribed by SAMUELSON OLAF RESIDENT on Nov-07-2022 1014) NYSTATIN TOPICAL 15 GM 1 APP TOPICAL TWICE DAILY POLYETHYLENE GLYCOL 17 GM ORALLY ONCE A DAY AS NEEDED for CONSTIPATION Sodium Bicarbonate Oral Tablet 650 MG 650 MG ORALLY TWICE DAILY SPIRONOLACTONE 25 MG ORALLY ONCE A DAY (ePrescribed by SAMUELSON OLAF RESIDENT on Nov-07-2022 1014) vit c 500 mg TID 500 MG ORALLY ONCE A DAY vit D3 1000 mg daily Continue taking same as home vit E 450 mg daily Continue taking same as home Discharge Disposition Transfer to skilled nursing facility   Plan Assessments: -Suspected transient ischemic attack, likely right MCA, MRI 11/2/22 shows no acute findings -Hypertensive emergency with neurological symptoms, requiring nicardipine drip, resolved -Resistant hypertension, requiring 7 medications, likely secondary to renal disease - Enterobacter cloacae urinary tract infection, acute, stable, started on ciprofloxacin 11/2/22 -COVID-19 infection, negative antigen test 10/31/22 -Acute headache -Hypomagnesemia, resolved -Nausea and vomiting, resolved -Atrial fibrillation, paroxysmal with indwelling pacemaker, rate-controlled -Chronic anticoagulation with Eliquis, renally dosed -CKD stage 4, diabetic nephropathy per biopsy at hospital -Recent complicated renal biopsy with hematoma -Diabetes mellitus type 2 with nephropathy, unknown control -Essential hypertension, uncontrolled -Hyperlipidemia -Normocytic anemia, likely of chronic kidney disease, stable -GERD  PLAN:  Patient has been deemed stable to transfer to nursing home for rehabilitation to home. She will require close follow up with several providers. --Patient will need a follow up appointment with Neurology. Please fax referral and MRI, CT results and discharge note. They will call the patient to schedule a follow up. --Patient will see her Cardiologist on December 3rd. Patient will need follow up regarding the MRI mode causing fasciculations in the pectoral muscle. --Nephrology follow up: Please fax: a face sheet, Labs from inpatient, and discharge summary to. Appointment already scheduled for Wed Nov 30th 10:30 AM.  --Follow up with patient's PCP will be made for within one week of hospital discharge.  Patient will be started on a significant regimen of anti-hypertensives. These changes are below. SPIRONOLACTONE 25 MG ORALLY ONCE A DAY LOSARTAN POTASSIUM 25 MG ORALLY EVERY DAY hydrALAZINE 50 MG ORALLY 3 TIMES A DAY cloNIDine HCL 0.2 MG/24HR 0.2 MG TRANSDERMAL EVERY WEEK amLODIPine BESYLATE 5 MG ORALLY DAILY AT BEDTIME  We would suggest hydralazine 50 for breakthrough requirements while in the nursing home, but do not believe patient is requiring these at this time.  Patient's UA grew Enterobacter cloacae. For her UTI she will be given CIPROFLOXACIN HCL 500 MG ORALLY ONCE A DAY For one additional day. Last dose 11/8/22.  Nephrology's recommendations have been reviewed. They suspect the creatinine to be at or approaching a new baseline, but there may be improvement as time passes from the contrast admission for her CTA.  Cardiology's recommendations have been reviewed. The pacemaker was successfully restored to the settings as previous to the MRI.  Neurology's recommendations have been reviewed. Patient has been increased from 20 mg to ATORVASTATIN CALCIUM 80 MG ORALLY DAILY AT BEDTIME and started on ASPIRIN LOW DOSE 81 MG ORALLY ONCE A DAY  Patient requires a blood draw for: BMP, diagnosis of elevated creatinine to be completed on 11/14/22  Two to three days before discharge, patient was experiencing some constipation. Scheduled Miralax was started. Before discharge this was made 'as needed' for constipation. Patient was encouraged to ask for therapy if needed.  Primary Care Provider   Electronically signed by RESIDENT on Nov-07-2022 1500