Age: 55.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin decreased, Intensive care, Left atrial enlargement, Mitral valve incompetence, Red blood cell transfusion
Clinical narrative: Patient ID: MRN:  Name:  Age: 56 y.o. Admit Date: 8/8/2022  6:54 PM Discharge Date:  08/10/22  Unit: Admitting Physician:  Discharge Physician: DO   Discharge Diagnosis: Principal Problem:   Anemia in neoplastic disease Active Problems:   Essential hypertension   Mixed hyperlipidemia   Hypokalemia   Hypomagnesemia   Elevated troponin   COVID-19 virus infection   Smoking addiction   CLL (chronic lymphocytic leukemia)      Hospital Course: Patient was admitted with anemia due to malignancy and chemo.  His Hgb was 4.  He received 2 U PRBC and it improved.  He was still weak but improved.  He decided today he would leave AMA.  Discussed risk of loss of life or limb. Pt voiced understand however elected to d/c from hospital to home. Instruction given to return in event of recurrent symptoms, chest pain, sob or over bleeding         Physical Exam on the Date of Discharge: Physical exam:  General Appearance: alert, NAD  Neck: no JVD, no LN enlargement  Lungs: clear, no wheezing   Heart: RRR, S1 S2 heard  Abdomen / GI: soft, non-tender, no ascites  Extremities / musculoskeletal: no edema, no synovitis   Skin: no rash, dry skin  Neuro: follows commands, moves extremities            Consults:   IP CONSULT TO ONCOLOGY/HEMATOLOGY IP CONSULT TO CARDIOLOGY IP CONSULT TO GASTROENTEROLOGY   Significant Diagnostic Studies:    Interpretation Summary There is no recent comparison study available. Aortic Valve No aortic regurgitation is present. No hemodynamically significant valvular aortic stenosis. Atria The left atrial volume index is 'mildly enlarged (35-41 ml/m2).'. Right atrial size is normal. Great Vessels The aorta at the Sinuses of Valsalva is '3.3' cm in diameter. The aortic root is normal size. The ascending aorta is '3.1' cm in diameter, at the maximal visualized area. The inferior vena cava appeared normal (<2.1 cm) and decreased > 50% with respiration (RAP 0-5 mmHg). Estimated RAP of 3 mmHg. Left Ventricle The left ventricular end-diastolic dimension is 'normal for men (4.2-5.8cm).'. There is no thrombus. There is normal left ventricular wall thickness. Left ventricular ejection fraction is '55%-60%' based on biplane method. Normal left ventricular systolic and diastolic function Mitral Valve There is no mitral valve stenosis. There is mild mitral regurgitation. Pericardium/Pleural There is no pericardial effusion. There is no pleural effusion. Procedure The exam was diagnostic. Complete  2D MMode  echocardiogram. Complete spectral Doppler interrogation Color flow velocity mapping. Exam  was performed on 'EPIQ' Examination was completed  in the intensive care unit. Pulmonic Valve There is no pulmonic valvular regurgitation. Right Ventricle The right ventricular basal-cavity dimensionis 'dilated >4.2cm.' The estimated global right ventricular systolic function based upon the tricuspid annular plane of systolic exursion (TAPSE) is 'normal >17mm.' The estimated global right ventricular systolic function based upon the TDE maximal myocardial systolic velocity S' is 'normal >10 cm/s.' Tricuspid Valve There is no tricuspid stenosis. There is trace tricuspid regurgitation. MMode 2D Measurements & Calculations Doppler Measurements & Calculations Boston Z-Scores(Vital Signs) Classic Z-Scores(Vital Signs) Detroit Z-Scores(Vital Signs) Other Measurements & Calculations Conclusion   Normal left ventricular systolic and diastolic function Left ventricular ejection fraction is '55%-60%' based on biplane method. There is mild mitral regurgitation.         Disposition:  AMA   Discharge Condition:  AMA   Discharge Medications and Orders:   Current Discharge Medication List   CONTINUE these medications which have NOT CHANGED   Details ibuprofen (MOTRIN) 800 mg tablet Take 1 Tablet by mouth EVERY 6 TO 8 HOURS PRN for Pain. Qty: 30 Tablet, Refills: 0   Associated Diagnoses: CLL (chronic lymphocytic leukemia); Arthritis   loperamide (IMODIUM A-D) 2 mg capsule Take 1 Capsule by mouth As directed. Take 1 to 2 caps after each loose stool, not to exceed 8 caps (16mg) in 24 hours. Qty: 60 Capsule, Refills: 2   Associated Diagnoses: CLL (chronic lymphocytic leukemia)   !! prochlorperazine (COMPAZINE) 10 mg tablet Take 1 Tablet by mouth Every 6 hours as needed for Nausea or Vomiting. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Chemotherapy-induced nausea   !! ondansetron HCL (ZOFRAN) 8 mg tablet Take 1 Tablet by mouth Every 8 hours as needed for Nausea. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Chemotherapy-induced nausea   loratadine (CLARITIN) 10 mg tablet Take 10 mg by mouth.   folic acid (FOLVITE) 1 mg tablet Take 1 Tablet by mouth Daily for 90 days. Qty: 90 Tablet, Refills: 0   Associated Diagnoses: Folic acid deficiency   omeprazole magnesium (PRILOSEC) 20 mg DR tablet Take 1 Tablet by mouth Daily for 90 days. Qty: 90 Tablet, Refills: 0   Associated Diagnoses: Gastroesophageal reflux disease without esophagitis   fenofibrate (TRIGLIDE) 160 mg tablet Take 1 Tablet by mouth Daily for 90 days. Indications: excessive fat in the blood Qty: 90 Tablet, Refills: 0   Associated Diagnoses: Mixed hyperlipidemia   amLODIPine (NORVASC) 10 mg tablet Take 1 Tablet by mouth Once Daily for 90 days. Qty: 90 Tablet, Refills: 0   Associated Diagnoses: Essential hypertension   !! prochlorperazine (COMPAZINE) 10 mg tablet Take 1 Tablet by mouth Every 6 hours as needed for Nausea or Vomiting. Use 1st Qty: 120 Tablet, Refills: 2   Associated Diagnoses: CLL (chronic lymphocytic leukemia)   !! ondansetron HCL (ZOFRAN) 8 mg tablet Take 1 Tablet by mouth Every 8 hours as needed for Nausea. Qty: 60 Tablet, Refills: 5   Associated Diagnoses: CLL (chronic lymphocytic leukemia)   venetoclax (VENCLEXTA) 10 mg-50 mg- 100 mg tablet Take as directed on dose pack. Starting on Cycle 1, Day 1, take two 10 mg tabs (20 mg) daily for one week. Then take one 50 mg tab daily for one week. Then take one 100 mg tab for one week. Then take two 100 mg tabs (200 mg) for one week. Take with water and a meal around the same time each day. Qty: 42 Tablet, Refills: 0   Associated Diagnoses: CLL (chronic lymphocytic leukemia)   venetoclax (VENCLEXTA) 100 mg tablet Take 4 Tabs by mouth Once Daily. Take with water and a full meal around the same time each day. Qty: 120 Tablet, Refills: 5   Associated Diagnoses: CLL (chronic lymphocytic leukemia)    !! - Potential duplicate medications found. Please discuss with provider.   STOP taking these medications     HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet Comments:  Reason for Stopping: