Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial fibrillation, Bronchitis bacterial, Bronchitis chronic, COVID-19 pneumonia, Computerised tomogram thorax normal
Clinical narrative: Patient ID: 91 y.o.    Admit Date:  8/9/2022   Discharge Date:   8/12/2022   Discharge Diagnosis:  Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Hypokalemia   Paroxysmal atrial fibrillation     Hospital Course:  91 year old male with COPD and a fib was admitted for Covid-19 pneumonia and hypokalemia. He had been vaccinated previously. He was treated with Remdesivir, steroids and empiric antibiotics. D dimer was severely elevated but CT chest and BLE venous US did not show thrombus. He will be discharged home today in stable condition. 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: 97.9 °F (36.6 °C) Heart Rate (Monitor): 87 Pulse: 81 BP: 155/87 Respirations: 18 SpO2: 98 % O2 Flow Rate (l/min): 0 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  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert   Consults:  IP CONSULT TO PULMONOLOGY IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:   CT chest, BLE venous US   Operations: none   Disposition:  Home    Discharge Condition:  Fair    Discharge Medications:   Current Discharge Medication List   CONTINUE these medications which have NOT CHANGED   Details potassium chloride (KLOR-CON) 10 mEq tablet Take 1 Tablet by mouth Once Daily. Qty: 30 Tablet, Refills: 2   Associated Diagnoses: Peripheral edema   ferrous sulfate 325 mg (65 mg iron) DR tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Iron deficiency anemia due to chronic blood loss   pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Iron deficiency anemia due to chronic blood loss   aspirin 81 mg chewable tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Paroxysmal atrial fibrillation with RVR   fluticasone-umeclidin-vilanterol (TRELEGY ELLIPTA) 100-62.5-25 mcg inhaler Take 1 Puff by inhalation Once Daily. Qty: 1 Each, Refills: 3   Associated Diagnoses: Mucopurulent chronic bronchitis   albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler Take 2 Puffs by inhalation Twice daily. Qty: 1 Each, Refills: 2   Associated Diagnoses: Simple chronic bronchitis   furosemide (LASIX) 20 mg tablet Take 1 Tablet by mouth Once Daily. Qty: 30 Tablet, Refills: 3   Associated Diagnoses: Peripheral edema   levothyroxine (SYNTHROID) 25 mcg tablet Take 1 Tablet by mouth Once Daily. Qty: 30 Tablet, Refills: 3   Associated Diagnoses: Acquired hypothyroidism   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. Qty: 150 mL, Refills: 3   Associated Diagnoses: Simple chronic bronchitis   Vit C-Vit E-Copper-ZnOx-Lutein 226-200-5 mg-unit-mg Cap Take  by mouth Daily. Indications: preservision           Patient Instructions: Discharge Procedure Orders Ambulatory referral to Home Health Referral Priority: Routine Referral Type: Home Health Evaluation Referral Reason: Continuity of Care Number of Visits Requested: 1 Expiration Date: 08/12/23   Diet Regular   Activity As Tolerated