Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Hyperlipidaemia, Hypertension, Left ventricular failure, Liver function test abnormal, Low density lipoprotein normal
Clinical narrative: ? (Principal) SYNCOPE   ? CAD WO ANGINA, PRESENCE OF STENT       4/15/2019 CCL eval with atypical s/s rt dom, LM:0%, LAD: <10% prox and 30% ISR mid LAD, CIRC: <10% mid, RCA: CTO mid w/L-R collats Remote PCI with stent placed. Patient cannot recall any details.   ? ASYMPTOMATIC COVID-19 DISEASE   ? SYSTOLIC HEART FAILURE, UNSPECIFIED ACUITY   ? ELEVATED LIVER FUNCTION TEST   ? ACUTE ON CHRONIC RENAL FAILURE   ? ACUTE NON ST ELEVATION MI   ? DM 2 W CKD STAGE 2 (GFR 60-89 W OTHER KIDNEY DAMAGE MARKER) W HTN       6/5/2023 Ho, MD (AFM) - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Working closely with care manager Gets eye care outside of clinic (Dr) - asked him to send me his most recent retinal screening today Diabetes Flowsheet Link     Lab Results Component Value Date   HGA1C 8.9 (H) 03/01/2023   HGA1C 8.9 (H) 11/28/2022   HGA1C 8.2 (H) 08/05/2022   CR 1.92 (H) 03/01/2023   GFRESTIM 38 (L) 03/01/2023   GFRESTIM 39 (L) 11/28/2022   K 4.8 03/01/2023   MALBCREAT >250mcg (A) 03/01/2023      BP Readings from Last 1 Encounters: 01/04/23 132/59       ? MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE   ? REACTIVE AIRWAY DISEASE, UNSPECIFIED   ? PSORIASIS   ? HYPERLIPIDEMIA       6/5/2023 MD (AFM) - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Lipids Flowsheet Link    6/5/2023: ASCVD-Risk (A-Risk): 26.1%      Lab Results Component Value Date   Cholesterol 154 06/19/2020   Triglyceride 292 06/19/2020   HDL 36 (L) 06/19/2020   Low density lipoprotein calculated 60 06/19/2020       ? HTN (HYPERTENSION)       6/5/2023, MD (AFM) - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Has been off chlorthaldone for a few months (? Dropped off medication list) - Patient to email or phone me in 2 weeks to update me, earlier if worse., if elevated then will restart chlorthalaone blood pressure is 120/70 today Vitals Flowsheet Link     BP Readings from Last 3 Encounters: 01/04/23 132/59 12/12/22 151/60 11/28/22 147/60    Pulse Readings from Last 1 Encounters: 01/04/23 59    Lab Results Component Value Date   CR 1.92 (H) 03/01/2023   GFRESTIM 38 (L) 03/01/2023   GFRESTIM 39 (L) 11/28/2022   K 4.8 03/01/2023   NA 140 11/28/2022   MALBCREAT >250mcg (A) 03/01/2023         Resolved Hospital Problems   Diagnosis Date Resolved ? CASE / CARE MGMT, CHF, TRANSITIONAL CARE 10/13/2023     Primary Procedures:  Procedure(s): CARDIAC CATHETERIZATION RIGHT HEART INTRAAORTIC BALLOON PUMP INSERTION   Secondary Procedures:  CARDIAC CATH LAB PROC CARDIAC CATH LAB PROC   Consults: CARDIOLOGY - INITIAL INPATIENT CONSULTATION. CARDIOLOGY - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - INITIAL INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION.   Condition on Discharge:  stable   Code Status at Time of Discharge: Full Code   Discharge Disposition:  Transfer for complex cath           Note Details  Author (M.D.) File Time 10/16/2023  8:18 AM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine  Admission (Discharged) on 10/12/2023  Admission (Discharged) on 10/12/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  CORONARY ANGIOGRAPHY From 10/12/2023 to 10/17/2023 CORONARY ANGIOGRAPHY From 10/15/2023 to 10/17/2023  Hospital Problem List   HYPERLIPIDEMIA  HTN (HYPERTENSION)  PSORIASIS  REACTIVE AIRWAY DISEASE, UNSPECIFIED  MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE  DM 2 W CKD STAGE 2 (GFR 60-89 W OTHER KIDNEY DAMAGE MARKER) W HTN  SYSTOLIC HEART FAILURE, UNSPECIFIED ACUITY  SYNCOPE  ACUTE NON ST ELEVATION MI  ACUTE ON CHRONIC RENAL FAILURE  ELEVATED LIVER FUNCTION TEST  ASYMPTOMATIC COVID-19 DISEASE  CASE / CARE MGMT, CHF, TRANSITIONAL CARE  CAD WO ANGINA, PRESENCE OF STENT Care Timeline  10/12   Admitted 0730 10/16   Discharged 0957  Discharge   Acute Care Facility (another hospital) Medication Information  Unavailable: This encounter predates the concise medication summary feature. To view this encounter's medications you will need to open the encounter.