Age: 71.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Cardiomegaly, Cerebral atrophy, Cerebral small vessel ischaemic disease, Chest X-ray abnormal, Chronic kidney disease
Clinical narrative: Date of Service Feb-06-2022 1205  Date of Admission Admit Date: Feb-03-2022  Date of Discharge Date of discharge Feb-06-2022  Allergies Versed - Not Specified  Lorazepam - Not Specified  Imdur - Not Specified  Augmentin - Not Specified  Ceclor - Not Specified  Ultram - Not Specified  Lisinopril - Not Specified  Bactrim - Not Specified  Codeine - Not Specified  Ranexa - Not Specified  Gabapentin - Not Specified  Procedure(s) Performed None  Lab Results Feb-06-2022 0633 Chemistry GLUCOSE  337BUN  38CREAT  2.3MDRD GFR  28NA  132K  4.4CL  100CALCIUM  7.9ALK PHOS  377CO2  20.5AST  38ALT  88AST/ALT  0.4TL PROT  5.8ALBUMIN  2.5TBILI  0.3DBILI  0.1OSMO  286.8ANION GP  15.9BUN/CRE  16.5CRP  1.50 Feb-06-2022 0633 Hematology WBC  7.6RBC  2.94HGB  9.5HCT  28.0MCV  95.2MCH  32.3MCHC  33.9RDW  14.6RDWSD  50.5PLT  350MPV  10.0AUTONEU%  75.5AUTOLYM%  11.4AUTOMON%  8.8AUTOEOS%  1.8AUTOBAS%  0.5AUTONEU#  5.8AUTOLYM#  0.9AUTOMON#  0.7AUTOBAS#  0.0AUTOEOS#  0.1NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.15IG%  2.0 Feb-06-2022 0633 Serology PROCALC  0.14 Feb-05-2022 1924 Point Of Care  Feb-05-2022 1602 Point Of Care  Imaging Results Chest x-ray performed February 3, 2022. Findings:  Median sternotomy and CABG.  Stable cardiomegaly.  No focal consolidations or pulmonary edema.  No pneumothorax identified. Impression: Cardiomegaly without failure.  CT head /brain without contrast performed February 3, 2022. Findings:  Moderate diffuse atrophy.  Mild changes of chronic small vessel ischemic disease.  No midline shift or mass effect.  No hydrocephalus.  No intracranial masses are identified within the limits of a noncontrast CT.  No intracranial hemorrhage.  No extra-axial fluid.  No CT evidence of an acute infarct.  The visualized paranasal sinuses and mastoid air cells are essentially clear. Impression:  1.  No acute intracranial abnormalities.  2. Moderate diffuse atrophy 3. Mild changes of chronic small vessel ischemic disease  Right upper quadrant ultrasound  performed  February 4, 2022. Findings:  Liver:  Normal.  No masses identified on the provided images.  Main portal vein is intact.  Gallbladder: Cholecystectomy.  Common bile duct:  Common bile duct diameter is mildly dilated up to 1.2 cm, stable and likely secondary to prior cholecystectomy.  No visualized choledocholithiasis.  Pancreas:  Pancreas not well visualized secondary to overlying bowel gas.  Right kidney: Normal.  No hydronephrosis.  No nephrolithiasis or masses identified within the limits of the ultrasound.  Aorta: Proximal abdominal aorta not well visualized.  The distal abdominal aorta is normal in caliber. Impression:  1. Pancreas not well visualized secondary to overlying bowel gas.  2. Cholecystectomy.  3. Common bile duct diameter is mildly dilated up to 1.2cm, stable and likely secondary to prior cholecystectomy.  No visualized choledocholithiasis.  Echocardiogram performed February 4, 2022. Conclusions:  Normal left ventricular systolic function with LV EF greater than 60%.  Moderate left ventricular hypertrophy ( measuring 1.4-1.7 cm).  Normal left ventricular diastolic function for age as measured by tissue Doppler/ mitral Doppler indices.  Mild left atrial enlargement which is consistent with LA index volumes between 35-41 centimeters squared.  Aortic cusps appear mildly calcified.  Trileaflet aortic valve.  Small thick pericardial effusion.  No echocardiographic evidence to suggest pericardial tamponade.  Social History tobacco use Former Smoker, Started Feb-04-1969 to Feb-04-2002, Smoking Cessation No quit smoking 20 years ago  marital status Married  Health Concerns Type 2 diabetes mellitus  Hypertensive urgency  Headache  Elevated liver enzymes level  Post-acute COVID-19  Former Smoker  Father Deceased @ unknown age  Mother Deceased @ unknown age  Vital Signs Feb-06-2022 0801 T 97.8 RR 20 Feb-06-2022 0800 HR 83 BP   150 / 70 Feb-06-2022 0400 T 98.9 HR 83 RR 18 BP   143 / 70 O2Sat 96 Feb-06-2022 0000 O2Sat 95 PHYSICAL EXAM Constitutional: Patient is a 72-year-old male, who is pleasant, alert, active and cooperative during exam. In no acute distress. Cardiovascular: Heart rate and rhythm is regular. No murmurs or clicks noted. Radial, dorsalis pedis, and posterior tibial arteries are 2+ bilaterally. No peripheral edema noted. Respiratory: Lungs are clear to auscultation bilaterally. No wheezes or rales noted. No accessory muscle use. GI: Normoactive bowel sounds. Abdomen is soft, non-tender to palpation. No guarding or rebound tenderness.  GU:  Foley catheter in place draining clear yellow urine Psych: Patient is alert and oriented. Mood and affect is appropriate.  Hospital Course The patient is a 72-year-old male who presented to the emergency department on February 3rd due to symptoms of nausea, vomiting, and diarrhea that had been going on for around a week. Of note he had tested positive for COVID on January 26 of 2022. While in the emergency room, it was discovered that he was hypertensive up into the 210 systolic. He admit to a headache in addition to the nausea. He was admitted for further treatment for his hypertension, as well as monitoring of his elevated liver enzymes. While he was COVID positive, he did not require any supplemental oxygen and is having minimal respiratory symptoms admission.  He was started on a clonidine patch in hopes of improving his blood pressure. He also had access to as needed IV medication if his hypertension became worse. The day after admission he was started on his home medications for blood pressure. He was also noted that he took prednisone daily at home and this was increased to a stress dose. While he is in the hospital, his glucose levels were elevated in part due to the increase of his steroid. He was started on long-acting insulin as well as sliding scale insulin and both of these were slowly increased during his hospitalization.  Workup of his elevated liver enzymes included a right upper quadrant ultrasound as well as laboratory studies. No fatty infiltration of his liver was noted by radiology. Hepatitis panel and alpha 1 anti trypsin are still pending at time of discharge. His liver enzymes did steadily improve during his hospitalization.  On the day of discharge, his blood pressures had improved and his symptoms had resolved he was eager to go home. On discharge, he was instructed that he can resume all of his home medications.  Condition at Discharge Stable  Discharge Medications allopurinol 300 mg tab 300 MG ORALLY ONCE A DAY aspirin 325 mg tab 325 MG ORALLY ONCE A DAY atorvastatin 80 mg tab 80 MG ORALLY DAILY AT BEDTIME carvedilol 25 mg tab 25 MG ORALLY TWICE DAILY clonidine HCl 0.3 mg tab 0.3 MG ORALLY TWICE DAILY escitalopram oxalate 20 mg tab 20 MG ORALLY ONCE A DAY HumaLOG Junior KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML 15 UNT SUBCUTANEOUSLY WITH MEALS hydralazine 10 mg tab 10 MG ORALLY TWICE DAILY HYDROcodone-Acetaminophen Oral Tablet 5-325 MG Continue taking same as home Lantus U-100 Insulin 100 unit/mL soln 50 UNT SUBCUTANEOUS DAILY AT BEDTIME metolazone 2.5 mg tab 2.5 MG ORALLY EVERY WEEK nifedipine 60 mg TbER 60 MG ORALLY ONCE A DAY Nitroglycerin Sublingual Tablet Sublingual 0.4 MG 0.4 MG SUBLINGUAL AS NEEDED PER INDICATION for CHEST PAIN Ondansetron Oral Tablet Disintegrating 4 MG Continue taking same as home Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Pen-injector 2 MG/1.5ML 0.5 MG SUBCUTANEOUSLY EVERY WEEK pramipexole 0.125 mg tab 0.125 MG ORALLY TWICE DAILY prednisone 5 mg tab 10 MG ORALLY ONCE A DAY torsemide 100 mg tab 100 MG ORALLY ONCE A DAY Trileptal Oral Tablet 150 MG 150 MG ORALLY ONCE A DAY Vitamin D3 4000 IU 4000 IU ORALLY ONCE A DAY Discharge Disposition Discharge to home  Plan Assessment: - Sepsis, likely secondary to COVID-19, resolved - Hypertensive emergency, with headache and systolic pressures above 210, resolved - COVID-19 with a stable chest x-ray and without acute hypoxic respiratory failure - Elevated transaminases, likely secondary to hypertensive emergency vs COVID-19, improving - Pericardial effusion, unspecified etiology, per echocardiogram 2/4/22 - Intertriginous candidiasis, currently on miconazole powder - Essential hypertension,  - Nausea and vomiting, likely secondary to hypertensive emergency, resolved - Acute diarrhea, improved - Diabetes mellitus type 2 with polyneuropathy and nephropathy, uncontrolled, Hgb A1c 9.0 on 01/03/2022 - Chronic kidney disease stage IIIB A3 with a GFR of 35, Cr 1.9 at baseline - Anemia of chronic kidney disease, per history, hemoglobin of 9.9 on 2/5 - Radiation cystitis, stable - Metabolic syndrome - Hyperlipidemia, per history  - History of prostate cancer - Coronary artery disease, s/p CABG x4 and stent placement - Lumbago, chronic - BMI 38.01, Class 2 obesity  Plan: The patient will be discharged home today.   His hypertension has resolved and liver function has improved.  He feels well enough to go home and wife is agreeable to come pick him up today.  We have made no changes to his home medications and upon discharge he can resume taking them as he did prior to admission.   Would like for him to call on Monday to get a follow-up appointment with his primary care provider.  I have communicated these instructions to his wife as well.   At time of discharge, hepatitis panel and alpha 1 antitrypsin testing is still pending.  Primary Care Provider (Privacy)  Electronically signed by (Privacy) DO RESIDENT on Feb-06-2022 1241 I have seen examined the patient on the day discharge agree with the discharge summary as documented by Dr (Privacy), PGY -3. Dr. (Privacy) and I have discussed the physical exam findings and plan for discharge today A total of 18 minutes was spent in the discharge of this patient today including the time spent evaluating him this morning, reviewing laboratory data, performing medication reconciliation with the resident, and documenting this note. Electronically signed by (Privacy) DO on Feb-06-2022 1555