Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Iron deficiency, Iron deficiency anaemia, Localised oedema, Lower urinary tract symptoms, Paracentesis
Clinical narrative: 76 y.o.   Admit Date:  7/31/2022   Discharge Date:   8/8/2022   Discharge Diagnosis:  Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Alcoholic cirrhosis of liver with ascites   NSTEMI (non-ST elevated myocardial infarction)   Acute diastolic CHF (congestive heart failure)   Benign essential HTN     Hospital Course:  76 year old resident was admitted for Covid-19 pneumonia. He was treated with 5 day Remdesivir therapy. He had previously received vaccine booster. Cardiology was involved for MI and he was initially on Heparin drip which was later stopped due to anemia. He required blood transfusion. He was diuresed by cardiology for CHF. He had paracentesis with removal of 1500 cc by IR. He will be transferred back to residence today in stable condition. Total discharge time >30 minutes. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.7 °F (36.5 °C) Heart Rate (Monitor): 71 Pulse: 75 BP: 111/60 Respirations: 14 SpO2: 93 % O2 Flow Rate (l/min): 2 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender, distended Skin: No rashes or lesions  Extremities: no edema Neuro: alert   Consults:  IP CONSULT TO CARDIOLOGY IP CONSULT TO INTERVENTIONAL RADIOLOGY IP CONSULT TO WOUND CARE IP CONSULT TO SOCIAL WORK IP CONSULT TO GASTROENTEROLOGY   Significant Diagnostic Studies:   TTE   Operations: paracentesis   Disposition:  Nursing facility   Discharge Condition:  Fair    Discharge Medications:   Current Discharge Medication List   CONTINUE these medications which have CHANGED   Details furosemide (LASIX) 40 mg tablet Take 1.5 Tabs by mouth Twice a day. Qty: 180 Tablet, Refills: 3   Associated Diagnoses: Localized edema     CONTINUE these medications which have NOT CHANGED   Details bisacodyL (DULCOLAX) 10 mg suppository Insert 10 mg rectally Every 72 hours. PRN for constipation   sodium phosphates (FLEETS) 19-7 gram/118 mL Enem enema Insert 1 Enema rectally Every 72 hours. PRN for constipation   ipratropium-albuteroL (DUO-NEB) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulizer solution Take 3 mL by nebulization Every 6 hours as needed for Wheezing.   Arginine-Glutamine-Calcium HMB (JUVEN) 7-7-1.5 gram PwPk Take 1 Packet by mouth Twice a day.   magnesium hydroxide (MILK OF MAGNESIA) suspension Take 30 mL by mouth Every 72 hours. PRN for constipation   ascorbic acid, vitamin C, 500 mg tablet Take 500 mg by mouth Twice a day. For 14 days beginning 7/25/2022   cholecalciferol, vitamin D3, 4,000 unit Tab Take  by mouth Once Daily. 4,000 unit tab daily for 14 days starting 7/25/2022   Ferrous Sulfate (IRON, FERROUS SULFATE,) 325 mg (65 mg iron) tablet Take 1 Tablet by mouth Twice a day. Qty: 100 Tablet, Refills: 0   Associated Diagnoses: Iron deficiency anemia due to chronic blood loss   docusate sodium (COLACE) 100 mg capsule Take 1 Capsule by mouth Twice a day. Qty: 60 Capsule, Refills: 0   Associated Diagnoses: Iron deficiency anemia secondary to blood loss (chronic)   sodium bicarbonate 650 mg tablet Take 2 Tabs by mouth Twice a day. Qty: 120 Tablet, Refills: 0   Associated Diagnoses: Hyponatremia   honey 100% (MEDIHONEY) 100 % Pste paste 1 Each by Topical route Once Daily. Refills: 0   Associated Diagnoses: Wound of sacral region, initial encounter   omeprazole (PRILOSEC) 20 mg DR capsule Take 20 mg by mouth Twice a day. Indications: gastroesophageal reflux disease   simvastatin (ZOCOR) 40 mg tablet Take 1 Tablet by mouth At bedtime. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Mixed hyperlipidemia; Type 2 diabetes mellitus without complication, without long-term current use of insulin   Ursodiol 250 mg Tab Take 250 mg by mouth Three times a day. Qty: 270 Tablet, Refills: 3   Associated Diagnoses: Cirrhosis   tamsulosin (FLOMAX) 0.4 mg capsule Take 1 Capsule by mouth Once Daily. Qty: 90 Capsule, Refills: 3   Associated Diagnoses: BPH with obstruction/lower urinary tract symptoms   folic acid (FOLVITE) 1 mg tablet Take 1 Tablet by mouth Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Iron deficiency           Patient Instructions: Discharge Procedure Orders Diet Cardiac   Activity As Tolerated