Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: AST/ALT ratio, Acute respiratory failure, Alanine aminotransferase normal, Anaemia, Anion gap
Clinical narrative: Date of Service Aug-01-2022 0812  Date of Admission Admit Date: Jul-29-2022  Date of Discharge Date of discharge Aug-01-2022  Allergies No Known Allergies  Chief Complaint shortness of breath  Procedure(s) Performed None  Lab Results Aug-01-2022 0643 Serology PROCALC  <0.05 Aug-01-2022 0620 Chemistry MAGNESIU  1.5 Aug-01-2022 0504 Chemistry GLUCOSE  113BUN  14CREAT  0.8MDRD GFR  96NA  134K  4.0CL  96CALCIUM  8.3CO2  36.3OSMO  269.5ANION GP  5.7BUN/CRE  17.5CRP  <0.05 Aug-01-2022 0504 Hematology WBC  12.7RBC  2.91HGB  9.0HCT  27.1MCV  93.1MCH  30.9MCHC  33.2RDW  14.6RDWSD  49.0PLT  181MPV  9.8AUTONEU%  84.3AUTOLYM%  7.2AUTOMON%  7.6AUTOEOS%  0.2AUTOBAS%  0.1AUTONEU#  10.7AUTOLYM#  0.9AUTOMON#  1.0AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.08IG%  0.6 Jul-31-2022 1951 Rad 1610164   Jul-31-2022 1605 Hematology HGB  10.1HCT  30.2 Jul-31-2022 1106 Blood Bank PRBC  Issued OposUNIT#  EXP DATE  08/10/22 Jul-31-2022 0815 Blood Bank PRBC  Issued O PosUNIT#  EXP DATE  08/10/22 Jul-31-2022 0700 Blood Bank ABO  ORH  PosAB SC  NegCROSS #1  CompCROSS #1  CompCROSS#2  Comp Jul-31-2022 0510 Chemistry GLUCOSE  128BUN  11CREAT  0.6MDRD GFR  134NA  131K  4.0CL  94CALCIUM  8.0ALK PHOS  67CO2  35.8AST  16ALT  14AST/ALT  1.1TL PROT  5.1ALBUMIN  2.6TBILI  0.2OSMO  263.7ANION GP  5.2BUN/CRE  18.3CRP  <0.1MAGNESIU  1.5 Jul-31-2022 0510 Hematology WBC  19.4RBC  2.15HGB  6.8HCT  19.8MCV  92.1MCH  31.6MCHC  34.3RDW  13.1RDWSD  44.1PLT  401MPV  9.1AUTONEU%  91.7AUTOLYM%  3.3AUTOMON%  4.2AUTOEOS%  0.1AUTOBAS%  0.1AUTONEU#  17.8AUTOLYM#  0.6AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.9PSMEAR  To IG#  0.11IG%  0.6 Jul-31-2022 0510 Serology PROCALC  <0.05 Jul-31-2022 0343 Chemistry TROPI-HS  9 Jul-31-2022 0209 Chemistry GLUCOSE  137BUN  13CREAT  0.6MDRD GFR  134NA  129K  4.4CL  91CALCIUM  8.6ALK PHOS  94CO2  35.6AST  18ALT  16AST/ALT  1.1TL PROT  6.0ALBUMIN  3.1TBILI  0.2OSMO  261.2ANION GP  6.8BUN/CRE  21.7TROPI-HS  10 Jul-31-2022 0209 Coagulation PT  10.9INR  1.0D-DIMER  0.26 Jul-31-2022 0208 Blood Gas PH VEN  7.37PCO2 VEN  63.8PO2 VEN  39BICARB V  35.7BE VEN  9.6CO2 CT V  34.4O2 SAT V  80.4 Jul-30-2022 0615 Chemistry GLUCOSE  154BUN  15CREAT  0.7MDRD GFR  112NA  128K  4.5CL  90CALCIUM  8.2CO2  35.9OSMO  261.0ANION GP  6.6BUN/CRE  21.4 Jul-30-2022 0040 Chemistry NA-U  16OSMO-U  435 Jul-29-2022 2050 Blood Gas PH  7.390PC02  63.1PO2 ART  127.0BICARB  37.3BE  11.0CO2 CT  35.1O2 SAT  98.9O2 THER  40TYPEABG  Arterial Jul-29-2022 1829 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  NCVDEMPHC  NCVDSYMP  NCVDSYMDT  UCVDHOSP  NCVDICU  NCVDRESID  NCVDPREG  N Jul-29-2022 1740 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Jul-29-2022 1714 Blood Gas PH VEN  7.30PCO2 VEN  91.3PO2 VEN  28BICARB V  43.5BE VEN  14.5CO2 CT V  41.8O2 SAT V  42.3 Jul-29-2022 1714 Chemistry GLUCOSE  106BUN  13CREAT  0.7MDRD GFR  112NA  126K  4.6CL  84CALCIUM  8.7ALK PHOS  108CO2  40.0AST  23ALT  18AST/ALT  1.3TL PROT  7.2ALBUMIN  3.5TBILI  0.2OSMO  253.9ANION GP  6.6BUN/CRE  18.6CRP  0.20LACTATE  1.10CK-MB  4.0MYO  40TROPI-HS  12 Jul-29-2022 1714 Hematology WBC  12.5RBC  3.41HGB  10.6HCT  31.2MCV  91.5MCH  31.1MCHC  34.0RDW  13.2RDWSD  43.6PLT  622MPV  8.8AUTONEU%  71.2AUTOLYM%  12.9AUTOMON%  9.6AUTOEOS%  4.8AUTOBAS%  0.7AUTONEU#  8.9AUTOLYM#  1.6AUTOMON#  1.2AUTOBAS#  0.1AUTOEOS#  0.6NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.10IG%  0.8 Jul-29-2022 1714 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Jul-29-2022 1714 Serology PROCALC  <0.05 Imaging Results CR - Chest 2 views (PA or AP and lateral) performed on 07/31/2022 Findings: No consolidation or effusion. A small calcified granuloma is located in the apex of the LEFT lung. Heart size normal. No acute fracture. Impression: There is hyperinflation with emphysematous changes. There is mild peripheral LEFT mid lung pleural thickening in the region of prior healed rib fractures. Electronically signed on Jul 31, 2022 4:16:05 PM by: MD   EKG performed on 07/31/2022 Sinus rhythm Borderline right axis deviation Probable anteroseptal infarct, old Electronically Signed On 8-1-2022 8:42:10 by DO  CR - Chest 1 view performed on 7/31/2022 FINDINGS: Mild to moderate centrilobular emphysematous disease changes. Mild chronic interstitial thickening. The lungs are clear of infiltrate. Incidental benign calcified lung parenchymal granuloma. No pleural effusion or pneumothorax. Cardiac size and mediastinal contours within normal limits. No acute displaced fracture or aggressive appearing osseous lesion. IMPRESSION: No radiographically evident acute cardiopulmonary pathologic process. Electronically signed on Jul 31, 2022 4:12:14 AM by:  MD  CH-CHEST 1V DR performed on 07/29/22 IMPRESSION: No significant change since 7/20/2022. DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 7/29/2022 5:36 PM  CT chest with contrast Impression: 1. Normal caliber thoracic aorta. No evidence of mediastinal hematoma or pneumomediastinum. 2. Centrilobular emphysema. Spiculated nodular opacity left upper lobe measuring 2.1 x 1.3 cm with adjacent pleural thickening inflammatory versus neoplastic will need follow-up. No pleural effusions or pneumothorax. 3. Nondisplaced left fourth rib fracture possibly acute. Electronically signed on Jun 25, 2022 5:58:56 AM by: MD Board of Radiology  Functional Status* No Functional Impairments  Mental Status* Normal Cognition  Social History tobacco use Current Every Day Smoker, 1 1/2 Packs Per Day, Smoking Cessation Yes  alcohol use Beer, Current, 36 Drinks Per Day  drug use No Known Use  marital status Divorced  He lives alone   Health Concerns Tobacco user  Current Every Day Smoker, 1 1/2 Packs Per Day  Beer, Current, 36 Drinks Per Day  Father Deceased @ unknown age Heart disease; Malignant neoplastic disease  Mother Deceased @ unknown age Alcoholism; Tobacco user  Tobacco Cessation* FDA Tobacco Cessation Medication has been prescribed (see discharge medications)  Vital Signs Aug-01-2022 0629 T 98.4 HR 82 RR 17 BP   150 / 71 O2Sat 100 O2L 4 Aug-01-2022 0542 WGT 126.1 Jul-30-2022 1200 T 98.4 HR 76 RR     24 BP   136 / 72 O2Sat 100 O2L 3 Pt is on 4L supplemental oxygen via nasal cannula.  PHYSICAL EXAM CONSTITUTIONAL: Patient is sitting up in bed, is in no acute distress at this time. Patient appears slightly diaphoretic as he complained that the room was too hot.  CARDIOVASCULAR: Regular rate and rhythm without murmur, gallop, or rub. No edema present in the lower extremities. Radial pulses intact 2+ bilaterally. RESPIRATORY: Decreased lung sounds. No wheezing, rhonchi, or rales appreciated. Patient is on 4L O2 nasal cannula. GASTROINTESTINAL: Abdomen is soft, non-tender to palpation. No rebound or guarding. No distension. No ascites. No organomegaly appreciated. MUSKULOSKELETAL: chronically ill-appearing NEUROLOGICAL: AOx4, normal sensation on upper and lower extremities. PSYCHIATRIC: RASS = 0. Patient responds appropriately to questions and displays normal affect.  Consultations No consultations  Hospital Course Patient is a 68 y/o male who presented to the ED on 7/29/22 for shortness of breath secondary to COPD exacerbation. The likely cause of his exacerbation was that he had run out of his inhalers, and he can't afford to get new inhalers. Patient reports his home oxygen is set on 4-5L. Patient reports he is still smoking 1.5 packs a day and is trying to quit. He has a PMH of end stage COPD, HTN, CAD with 3x bypass, chronic alcoholism, tobacco use disorder, and prediabetes.   Patient was initially treated for his COPD exacerbation with BIPAP for approximately 30 minutes before he began to refuse it. He was made aware of the risks and benefits of BIPAP and continued to refuse BIPAP. His COPD exacerbation was then managed with oxygen via NC titrated to maintain oxygen saturation > 88%, doxycycline 100mg BID, cefepime 2g Q8H to cover pseudomonas due to a chronic alcoholism, albuterol Q6H per RT, guaifenesin 600mg BID, dexamethasone 6mg daily during his hospital stay.   On 7/29/22 his Hgb was found to be 10.6, which dropped to 6.8 on 7/31/22, and was suspected to have either GI bleed, esophageal varices, or it could have been dilutional after receiving fluids. He refused to have EGD done. As a precaution, his low Hgb was managed with 2 units PRBC, sucralfate before meals and at bedtime, pantoprazole 40mg twice daily before meals. Pt is at high risk for GI bleed/esophageal varices due to alcoholism.    On 7/31/22 at 0206, nursing reports that the patient's O2 sat suddenly dropped into the 50s. Patient's saturation improved after 15L non-rebreather and patient was worked up for PE and NSTEMI. Patient's O2 sat improved and he was titrated back to 3 L nasal cannula.  This morning (8/1/22), the patient denies any problems and states he is ready to go home to take care of his cats. Patient had reported that he is out of inhalers until the 7th of August because the insurance company will only pay for inhalers once a month. He states that respiratory therapy gave him some inhalers to take home to get him by until the 7th. Patient states that he is able to move around without any problems, and is able to urinate without issues. His last bowel movement was a couple days ago, but he states that this is not unusual for him. The patient improved overall and feels he is back to baseline. He was deemed ready for discharge.  Condition at Discharge Stable  Discharge Medications albuterol sulfate 90 mcg/actuation HFAA Continue taking same as home Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/INH 1 PUF INHALATION ONCE A DAY Aspirin Oral Tablet Chewable 81 MG 1 TAB CHEWED ONCE A DAY atorvastatin 40 mg tab 1 TAB ORALLY AT BEDTIME BENZONATATE Continue taking same as home carvedilol 3.125 mg tab 1 TAB ORALLY ONCE A DAY cetirizine 10 mg tab 1 TAB ORALLY ONCE A DAY clopidogrel 75 mg tab 1 TAB ORALLY ONCE A DAY Combivent Respimat Aerosol Solution 20-100 MCG/ACT 1 PUF INHALATION 4 TIMES A DAY fluoxetine 20 mg cap 3 CAP ORALLY ONCE A DAY GUAIFENESIN ER 600 MG ORALLY TWICE DAILY irbesartan 150 mg tab 1 TAB ORALLY ONCE A DAY Iron (Ferrous Sulfate) Tablet 325 (65 Fe) MG 325 MG ORALLY 3 TIMES A DAY isosorbide mononitrate 30 mg Tb24 1 TAB ORALLY ONCE A DAY levoFLOXacin Oral Tablet 750 MG 750 MG ORALLY ONCE A DAY NICOTINE TRANSDERMAL 21 MG / 24 HR 21 MG TRANSDERMAL ONCE A DAY Nitroglycerin Tablet 0.4 MG Continue taking same as home olanzapine 5 mg tab 1 TAB ORALLY AT BEDTIME PANTOPRAZOLE 40 MG ORALLY ONCE A DAY predniSONE Oral Tablet 20 MG 40 MG ORALLY ONCE A DAY predniSONE Tablet 10 MG 10 MG ORALLY ONCE A DAY SODIUM CHLORIDE 0.65% 45 ML Continue taking same as home SUCRALFATE 1 GM ORALLY BEFORE MEALS AND AT BEDTIME Discharge Disposition Discharge to home  Plan ASSESSMENT: - Sepsis secondary to COVID-19 infection vs pneumonia, improving  - Acute on chronic hypercapnic hypoxic respiratory failure secondary to acute exacerbation of chronic obstructive pulmonary disease, pH 7.37, pCO2 63.8 per venous blood gas on 7/31 - improving  - Acute exacerbation of chronic obstructive pulmonary disease secondary to COVID-19 infection, resulting in respiratory failure requiring BiPAP, improving currently on baseline oxygen 4L  - COVID-19 infection, symptom onset 7/24, positive test on 7/29 - Acute on chronic normocytic anemia, Hgb 10.6 and Hct 31.2 on admission, likely secondary from chronic alcoholism, Hgb 6.8 on 7/31/22 - Acute hypomagnesaemia, Mg 1.5 on 7/31/22, likely secondary to poor nutrition from alcoholism - Chronic hyponatremia, Na 126 on admission, likely secondary to poor nutrition from alcoholism, resolved - Chronic hypochloremia, Cl 84 on admission, likely secondary to malnutrition and alcoholism, persistent - Thrombocytosis, chronic intermittent, Plt 622 on admission, likely secondary to acute inflammatory response vs rebound thrombocytosis from chronic alcoholism, resolved - Acute leukocytosis, WBC 12.5 on admission, likely secondary to acute inflammatory response - Spiculate nodule opacity left upper lobe measuring 2.1 x 1.3 cm, per CT on 6/25/22 - Coronary artery disease with history of multiple coronary artery bypass graft, chronic, controlled on home medications - Long-term use of anticoagulants, clopidogrel  - Hypertension, chronic, unknown control on home medications - Hyperlipidemia, chronic, unknown control on home medications - Gastroesophageal Reflux Disease, chronic, unknown control on home medications - Trivial mitral valve regurgitation on echocardiogram 2/21/22 - Mild aortic stenosis on echocardiogram 2/21/22 - Mild mitral valve regurgitation on echocardiogram 2/21/22 - Atherosclerotic peripheral vascular disease, chronic, per arterial doppler 3/21/22 - Moderate protein-calorie malnutrition, chronic - Tobacco use disorder, current 1.5 pack per day smoker - Alcohol dependence, current 2 shot and 4 beers per day drinker - Underweight, BMI 20.596  PLAN: The patient's condition is stable at this time and will be discharged today to home. We will discharge the patient on their home medications as reconciled above. We will send the patient home with levofloxacin 750 mg q.d. and prednisone 40 mg q.d. for 5 days on discharge for coverage of COVID and bacterial pneumonia. Patient tried Trelegy which helped him with his COPD however his insurance does not cover the medication. We called and spoke with the pharmacy and they said that he needs to try another inhaler before the Trelegy would be covered by insurance. We will start him on Anoro inhaler 1 puff qd; he is to discontinue his other inhalers other than the albuterol. Patient was found to have anemia (Hgb 6.8 on 7/31/22) and was given 2uPRBC. He refused EGD so we are unable to confirm GI bleed, but given significant risk factors for GI bleed and esophageal varices, we will have the patient take sucralfate 1gm qid and pantoprazole 40 mg qd. They are to resume a cardiac diet and resume activity as tolerated. We counseled the patient on alcohol and tobacco cessation. We recommend the patient follow up with PCP Dr. and an appointment was scheduled on 8/9/22 at 2:40pm for hospital follow-up for COPD exacerbation, anemia, blood smear results, and to go over the incidental finding of spiculated LUL lung nodule per CT 6/25/22.  The patient was seen and evaluated by Dr. and the plan of care was discussed with this resident.  DO Family Medicine, PGY-1  Primary Care Provider DO     DO  Electronically signed by RESIDENT DO on Aug-01-2022 1422 I have seen and physically examined the patient on 8/1/22 and agree with the documentation of PGY-1. I have also discussed my findings and plan of care with PGY-1. Any changes and additional information are listed below. Electronically signed by DO on Aug-01-2022 1847