Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Blood culture positive, COVID-19, COVID-19 pneumonia, Cardiac assistance device user
Clinical narrative: Date of Admission: 12/10/2023   Date of Discharge: 12/14/2023   Issues to be Addressed at Follow-up: none   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/14/2023  6:51 AM FERRITIN In process --   12/11/2023 10:11 AM BLOOD CULTURE 2 Preliminary BLOOD   12/11/2023 10:11 AM BLOOD CULTURE Preliminary BLOOD   12/10/2023  2:20 PM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? ANTICOAGULATION MONITORING, INR 2.0-3.0       Start date: 11-26-12  Indication: atrial fibrillation  End date: Indefinite Anticoagulation Service.       ? SICK SINUS SYNDROME   ? HYPOTHYROIDISM       Levothyroxine (LEVOTHROID/SYNTHROID) 50 mcg Oral Tab daily   ? HYPERLIPIDEMIA   ? HTN   ? GRAM NEG BACTEREMIA   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? DIASTOLIC HEART FAILURE, ACUTE ON CHRONIC   ? PRESENCE OF CARDIAC PACEMAKER        Implant 2/10/15 Not dependent   Pulse generator: Medtronic Adapta ADDRL01  dual  chamber pacemaker serial # NWE301242H.    Ventricular lead:  Medtronic Model # 4092 (passive)  52 cm lead, serial #  LEP559973V, implant settings  stimulation threshold of 0.5 volts at  0.5 milliseconds, sensed R-waves of 12.7 millivolts,  impedance  534 ohms.    Atrial leads:  Medtronic Capsurefix 4076  45 cm lead, serial # BBL1060634, stimulation threshold at  implant of 0.5 volts at 0.5  milliseconds, sensed P-waves of 1.7 millivolts, impedance of 576  ohms.   VVIR 60-120       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 98-year-old woman with history of paroxysmal A-fib, sick sinus syndrome, history of pacemaker, HTN, HLD, diastolic CHF, hypothyroidism.  She presented to the ED 12/10 with chills and lethargy.  She was diagnosed with COVID-19 pneumonia and mild hypoxemia.  She was started on dexamethasone, remdesivir, and also IV Lasix.  She grew 1 out of 2 blood cultures with gram-negative rods and she was continued on ceftriaxone.  She did not have any obvious source and UA was not suggestive of infection. She remained clinically well and weaned off O2 by 12/13. She had an episode of staring off and unable to be aroused for a few minutes on 12/14 after being in a chair for several hours suspicious for orthostatic syncope   COVID-19 DISEASE (12/10/2023) and  ACUTE HYPOXEMIC RESPIRATORY FAILURE (12/10/2023)   Assessment: improving on steroids, remdesivir, and diuresis. Weaned off O2   Plan: dexamethasone was given through 12/13            Remdesivir 5 doses.  Last dose 12/14.            No physical therapy needs at discharge            20 day isolation. Last day 12/29    DIASTOLIC HEART FAILURE, ACUTE ON CHRONIC (12/10/2023)   Assessment: fluid overloaded at admission but now improved after IV lasix   Plan: Will return 40mg daily for discharge   GRAM NEG BACTEREMIA (12/13/2023)   Assessment: uncertain cause. Could be contaminate. Could be pneumonia but unlikely. Negative UA. No signs of intraabdominal infection. Will give    Plan: Ceftriaxone 2 g daily was given 5 days while admitted            Stop azithromycin            will give 6 more days of duricef for empiric bacteremia treatment            Discussed empiric abx treatment vs doing further with CT scans to eval for malignancy or abscess. She opted for abx because she is not desiring procedures or cancer treatments at her age.   ANTICOAGULATION MONITORING, INR 2.0-3.0 (11/26/2012)   Assessment: on home coumadin   Plan: restarted coumadin            Digoxin 125mcg daily            Metoprolol 50mg bid   SICK SINUS SYNDROME (2/5/2015) and  PRESENCE OF CARDIAC PACEMAKER (9/23/2019)   Assessment: notd   Plan: outpatient follow   HYPOTHYROIDISM (2/4/1995)   Assessment: stable   Plan: Levothyroxine 50mcg daily   HTN (7/13/2001)   Assessment: stable   Plan: Lisinopril 40mg daily            metoprolol   HYPERLIPIDEMIA (4/29/2008)   Assessment: on home lovastatin 20mg qhs   Plan: lovastatin     Primary Procedures:  none   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  covid infection   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR   --------------------------   HBS progress noted:   Subjective: patient ready to go home. No shortness of breath. No cough. Walking. No dizziness. Discussed could have had low BP after sitting upright for so long yesterday. Updated daughter and granddaughter in hallway on progress. Agree to discharge. Discussed likely orthostasis from BM, iv lasix and advanced age yesterday. Discussed isolation period   Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 12/14/23 1530 98.4 °F (36.9 °C) Oral 69 157/82 19 94 % RA 12/14/23 1213 97.7 °F (36.5 °C) Oral 64 152/79 20 99 % RA 12/14/23 0816 98.2 °F (36.8 °C) Oral 74 165/99 17 100 % RA 12/14/23 0625 98.2 °F (36.8 °C) Oral 63 152/74 14 93 % RA 12/14/23 0000 98.2 °F (36.8 °C) Oral 72 142/55 19 93 % RA   Patient Vitals for the past 72 hrs:    Stool Characteristics Unmeasured Stool (#) 12/14/23 1355 Brown;Soft;Small 1 12/13/23 1901 Brown;Soft;Loose;Medium ? 12/13/23 1736 Brown;Soft;Loose;Medium ? 12/13/23 1227 Brown;Soft;Loose;Medium 1     Physical Exam General appearance - alert, elderly well appearing, and in no distress Mental Status - alert, oriented x 3, pleasant Eyes - extraocular eye movements intact, sclera anicteric Nose - normal and patent Throat - normal Chest - clear to auscultation, no wheezes, rales or rhonchi, rare cough Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs Abdomen - soft, nontender, nondistended, no masses or organomegaly Neurological - motor and sensory grossly normal bilaterally Extremities - no clubbing, cyanosis or edema, peripheral pulses present Skin - warm and dry       Note Details  Author (D.O.) File Time 12/14/2023 10:11 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct # Admit Date 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023   Routing History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   SmartForms:    STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   COVID-19 DISEASE  PRESENCE OF CARDIAC PACEMAKER  ACUTE HYPOXEMIC RESPIRATORY FAILURE  DIASTOLIC HEART FAILURE, ACUTE ON CHRONIC  GRAM NEG BACTEREMIA  ANTICOAGULATION MONITORING, INR 2.0-3.0  SICK SINUS SYNDROME  HYPOTHYROIDISM  HTN  HYPERLIPIDEMIA Care Timeline  12/10   Admitted from ED 2050 12/14   Discharged 1534  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 12/14/2023) Medication List at Discharge   cefadroxil 500 mg Oral EVERY 12 HOURS  digoxin 125 mcg Oral DAILY  furosemide 40 mg Oral DAILY  levothyroxine sodium 50 mcg Oral DAILY  lisinopril 40 mg Oral DAILY  loperamide HCl 2 mg Take 2 tablets by mouth after the first loose stool, then 1 tablet after each subsequent loose stool. Do not exceed 4 tablets in 24 hours. Take with 4 to 8 ounces of water  lovastatin 20 mg Oral EVERY EVENING  melatonin 3 mg Oral DAILY  metoprolol tartrate 50 mg Oral 2 TIMES A DAY  potassium chloride 10 mEq 10 mEq Oral DAILY  trazodone HCl 50 mg Oral EVERY BEDTIME  vit A/vit C/vit E/zinc/copper 2,148 mcg-113 mg-45 mg-17.4mg Take 2 tabs orally daily  warfarin sodium 2.5 mg Take as directed by physician or Anticoagulation clinic