Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Orthopnoea, Peripheral swelling, Prothrombin level, Pyrexia, Respiratory symptom
Clinical narrative: Date of Admission: 12/4/2023   Date of Discharge: 12/7/2023   Issues to be Addressed at Follow-up: Cardiology (E.consult placed)   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 11/6/2023 to 12/7/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? HEART FAILURE W NORMAL LVEF >=50%, UNSPECIFIED ACUITY       1/27/2023  Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Stable symptoms.   Plan Daily weights, low sodium diet, 2L fluid restriction Discussed lasix 20 mg daily   1/24/2022 - TAV LVEF> 60  States he has been taking Lasix daily. Has been feeling fatigued.  Requesting referral to cardiogist. No symptoms of orthopnea or leg swelling. States he is not having any excessive urination. Wt has been stable. Plan Referral done as requested       1/19/2022 - DOV Last Admit Date: 01/15/2022 BNP was in the 700s. States he was eating salted seafood. Noted some wt gain and orthopnea and leg swelling. . Symptoms are better now. Plan Monitor wt daily. If any symptoms of wt gain, leg sweling - to take lasix for 2-3 days. Educated on low salt diet Advised patient to email/call if any worsening/recurrence of sympts noted.         ? ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE       1/27/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.     ROS - no dizziness. No blood in stool or black stools.  On pradaxa HR controlled on BB on metoprolol 25 mg bid     ? OBSTRUCTIVE SLEEP APNEA       Date: 1/28/21  Study Type: WatchPat   pAHI: 59.1  BMI: 26.1   ESS: not completed by patient  Min SpO2: 66% SpO2<90%: 89 minutes Severe Sleep Apnea.     ? HTN (HYPERTENSION)       11/14/2023: Chronic established diagnosis. Briefly reviewed plan today, continue current regimen.   BP Readings from Last 3 Encounters: 11/14/23 141/56 10/15/23 148/76 10/04/23 158/68   On amlopidine 5 mg- not on it anymore Metoprolol 25 mg bid Losartan 75 mg     ROS neg   Plan Continue medications- increase lasix for a few days Monitor at home and e-mail me or walk in on Monday for blood pressure check Advised patient to email/call if any worsening/recurrence of sympts noted.       ? HYPERLIPIDEMIA       1/27/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  On statin     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 82-year-old man presents with 1 week of fever, cough, chest pain associated with his cough, URI type symptoms.  Patient noted to be COVID-19 positive, reports fatigue and weakness, patient noted to have elevated troponins of 243 (no current chest pain or pressure), denies SOB, N/V or diaphoresis.    Patient was admitted, he did not require supplemental O2, he was treated with Remdesivir for Covid, his main symptoms were cough.  His troponins peaked at 1300, cardiology did not recommend IV heparin (patient on anticoagulation with DOAC for atrial fibrillation, Plavix was added) Echo with mildly reduced EF, and wall motion abnormalities, patient will be followed up in cardiology clinic, he is on pradaxa, plavix, statin and beta blocker.    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Covid   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: Full Code       Note Details  Author (M.D.) File Time 12/7/2023  8:53 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 12/4/2023  ED to Hosp-Admission (Discharged) on 12/4/2023  ED to Hosp-Admission (Discharged) on 12/4/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HTN (HYPERTENSION)  HYPERLIPIDEMIA  OBSTRUCTIVE SLEEP APNEA  ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE  HEART FAILURE W NORMAL LVEF >=50%, UNSPECIFIED ACUITY Care Timeline  12/04   Admitted from ED (Observation) 2016 12/07   Discharged 1543  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/7/2023) Medication List at Discharge   clopidogrel bisulfate 75 mg Oral DAILY  dabigatran etexilate mesylate 150 mg Oral 2 TIMES A DAY, . Take with a full glass of water. Do not break, chew, or open capsule  doxycycline monohydrate 100 mg Oral 2 TIMES A DAY  furosemide 20 mg Oral DAILY  losartan potassium 50 mg Oral 2 TIMES A DAY  lovastatin 20 mg Oral EVERY EVENING WITH A MEAL  metoprolol tartrate 25 mg Oral 2 TIMES A DAY  testosterone 20.25 mg/1.25 gram (1.62 %) Apply 1 pump to skin daily . Apply to shoulders and/or upper arms at approximately the same time each day (Total daily dose = 1 pump)