Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Organ failure, Pleural effusion, Pulmonary oedema, SARS-CoV-2 test positive, Sepsis
Clinical narrative: Attestation signed by (M.D.) at 12/10/2023  9:42 AM   I have reviewed and verified the content of this Discharge Summary. The Discharge Summary accurately reflects the outcome of the patient?s hospitalization and/or treatment, the disposition of the patient, and the patient?s final diagnosis. I have verified that the Discharge Summary also provides for appropriate follow-up care to facilitate proper continuity of care.    Date of Admission: 12/8/2023   Date of Discharge: 12/9/2023   Issues to be Addressed at Follow-up:   #Sepsis, COVID19 -s/p IV decadron 10mg x1 in ED on 12/8 -IV Remdesivir: 12/8/23-12/9 - no supplemental oxygen requirement  -Follow blood and urine cultures    #DM2 - PTA NPH 5u BID   #ESRD #Hyperparathyrpoidism  - HD MWF, Nephro consulted; no HD required inpatient  - calcitriol, Vit B complex   #Elevated Troponin  - asymptomatic   #HTN - Amlodipine 5mg - Metop 25mg BID   #H/o breast, endometrial cancer  - Tamoxifen 20mg qd    Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/9/2023  5:30 AM MRSA SCREENING CULTURE In process NARES   12/8/2023 11:11 AM BLOOD CULTURE 2 Preliminary BLOOD   12/8/2023 11:00 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? COVID-19 DISEASE       Positive PCR 12/8/2023   ? ESRD ON DIALYSIS   ? DM 2 W CKD STAGE 4 (GFR 15-29)   ? FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, RIGHT CENTRAL PORTION   ? HYPERPARATHYROIDISM, UNSPECIFIED   ? DM 2 W HYPERLIPIDEMIA        Basename Value Date/Time ? HGBA1C % 7.9 (H) 09/20/2019    Basename Value Date/Time ? CHOLESTEROL                   160 11/22/2017 ? TRIGLYCERIDE               290 (H) 06/30/2014 ? HDL                        30 (L) 11/22/2017 ? LDL CALCULATED                 52 06/30/2014 ? LDL CALCULATED, NONFASTING NOT DONE 11/22/2017 ? TRIGLYCERIDE, NONFASTING      406 11/22/2017       ? HX OF ENDOMETRIAL CANCER       9/2008: endo bx: endometrioid adenocarcinoma.(Grade 2). Follow up: with pelvic (rectovaginal) exams and nodal surveys q3months for 2 yrs,  followed by q6 months for 3 yrs and annually thereafter.    ? HTN (HYPERTENSION)   ? HYPERLIPIDEMIA     Resolved Hospital Problems   Diagnosis Date Resolved ? (Principal) SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION 12/09/2023     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Patient is a 85 Y female with h/o ESRD on dialysis (MWF), hx of nephrectomy (1980), T2DM (A1c 7.9 4/2021), HLD, HTN, hyperparathyroidism, hx of endometrial cancer, right infiltrating ductal carcinoma stage IA, subarachnoid hemorrhage(2022) presented to the ED by EMS with complaint of altered mental status noted by staff during dialysis session. Vitals in ED were BP 188/69, T: 39.2, HR 108, RR 23, O2 95% and upon lab WBC 13.3, Hgb 11 with left shift, Cr 2.35 (labile Cr between 2-6), trop 27. LDH 1.7. EKG showed sinus tachycardia and 1st degree AV block. Chest XR noted mild pulmonary edema and small right sided pleural effusion. Given 10mg dexamethasone injection. Admitted 12/8 for Sepsis 2/2 COVID-19 disease.    Patient with mentation back to baseline by AM of hospital day #1. Remained afebrile, hemodynamically stable on room air. Patient reported feeling better and asked to go home. Assessed by PT and advised no further PT needs. Received Remdesivir x 2. Deemed medically safe for discharge home. Advised to schedule follow up appointment with her excellent primary care physician, Dr.     OBJECTIVE ON DAY OF DISCHARGE: Values over last 24 hours:  Vital Sign: [Lowest - Highest], and Most Recent (Date/Time of most recent)  Temp:  [98 °F (36.7 °C)-98.7 °F (37.1 °C)] 98.3 °F (36.8 °C) (12/09 1312) HR:  [62-92] 62 (12/09 1312) Resp:  [16-24] 20 (12/09 1312) SpO2:  [92 %-99 %] 97 % (12/09 1312) BP: (121-162)/(48-76) 149/68 (12/09 1312) Mean Arterial Pressure (Device):  [71-98] 94 (12/09 1312)   PHYSICAL EXAM ON DAY OF DISCHARGE: General appearance - alert, well appearing, and in no distress Mental Status - alert, oriented x3 (person, place, time) Chest - clear to auscultation bilaterally, no wheezes, rales or rhonchi Heart - regular rate and rhythm, normal S1 and S2. No murmurs, rubs, gallops.  Abdomen - soft, nontender, nondistended, no masses or organomegaly.Bowel sounds present Neurological - CN II-XII are intact. Strength 5/5 UE and LE. Sensation intact bilaterally.  Extremities - no clubbing, cyanosis or edema. Peripheral pulses present bilaterally.    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  COVID-19   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - INITIAL INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     OMS-IV Medical Student       Case discussed and plan developed with Dr., MD, attending physician Case discussed and plan developed with Dr., MD, senior resident physician          Cosigned by:  (M.D.) at 12/10/2023  9:42 AM  Note Details  Author  (M.D.) File Time 12/10/2023  9:42 AM Author Type PHYSICIAN, RESIDENT Status Signed Last Editor  (M.D.) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 12/8/2023  ED to Hosp-Admission (Discharged) on 12/8/2023  ED to Hosp-Admission (Discharged) on 12/8/2023   Revision History   Detailed Report  Note shared with patient Hospital Problem List   HYPERLIPIDEMIA  HTN (HYPERTENSION)  DM 2 W HYPERLIPIDEMIA  HYPERPARATHYROIDISM, UNSPECIFIED  FEMALE BREAST INFILTRATING DUCTAL CARCINOMA, RIGHT CENTRAL PORTION  DM 2 W CKD STAGE 4 (GFR 15-29)  ESRD ON DIALYSIS  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION Resolved  HX OF ENDOMETRIAL CANCER  COVID-19 DISEASE Care Timeline  12/08   Admitted from ED 2136 12/09   Discharged 2245  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/9/2023)   Discharge Orders BICARBONATE BUN CHLORIDE GLUCOSE SODIUM