Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Essential tremor, Faeces discoloured, Fatigue, Gastrooesophageal reflux disease, Glycosylated haemoglobin
Clinical narrative: Expand All Collapse All Discharge Summary   Date of Admission:  12/1/2023    Date of Discharge:  12/4/2023   Primary Care Physician:  MD   Issues to be Addressed in Follow-up: Physical therapy eval if deconditioning does not improve after completion of treatment   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/1/2023  2:15 AM BLOOD CULTURE 2 Preliminary BLOOD   12/1/2023  2:15 AM BLOOD CULTURE Preliminary BLOOD     Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? ATHEROSCLEROSIS OF AORTA       1/25/2023 - Chart Update  We will continue to monitor, noted on scans Low carbohydrate diet and exercise recommended     ? RESTLESS LEGS SYNDROME   ? DM 2        Basename Value Date/Time ? HGBA1C %    6.2 09/29/2016   03/09/2017  DM2 wo retinopathy resolved DM 2 WO COMPLICATIONS [E11.9] » DM 2 [E11.9]       ? RIGHT NORMAL TENSION GLAUCOMA, MILD STAGE       1/25/2023 - Chart Update  Stable, no complaints Using eyedrops and following up with ophthalmology     ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)        11/28/2023 MD     Has persistent , heartburn , wakes her up at night , symptoms 2 weeks  No nausea , no GI bleed  No anorexia  Weight is stable  Bm black stools 1-2 x a week as per pt  Takes iron prn which can cause black stools  Takes omeprazole but still has symptoms  Hx of duodenal ulcers   (M.D.)   Positive serology May 2014, Treatment with O/A/C in May 2014 EGD 9/15/2014 showed small shallow duodenal ulcers, gastric biopsies negative for H. Pylori.    On repeat EGD in 2016 , no ulcers seen        GERD with ? Melena  Plan : stop omeprazole  Change to pantoprazole 40 mg BID  Add sucralfate  Check occult blood stools check H and H        ? OBSTRUCTIVE SLEEP APNEA       2014 - does not tolerate CPAP - not using WATCHPAT AMBULATORY SLEEP STUDY       2/4/14 Diagnosis:    MODERATE OSA (AHI= 19; ODI = 10, Min O2 sat 84%; Mean O2 sat =89%), low baseline ESS = 4  Estimated body mass index is 31.45   ? BENIGN ESSENTIAL TREMOR       1/25/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Stable on propanolol No new complaints     ? HYPERLIPIDEMIA       1/25/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.    Lab Results Component Value Date   Cholesterol 146 12/10/2021   Triglyceride 103 12/10/2021   HDL 48 (L) 12/10/2021   Low density lipoprotein calculated 77 12/10/2021   Low carbohydrate diet and exercise recommended     ? OSTEOARTHRITIS   ? HTN (HYPERTENSION)       1/25/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.    BP Readings from Last 3 Encounters: 01/25/23 122/50 01/17/23 92/46 09/21/22 157/56   At goal Continue lisinopril 20 mg Low carbohydrate diet and exercise recommended       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   HPI on Admission from by Dr.:  Patient is a 85 Y  female with history of hypertension, DM 2, hyperlipidemia, obstructive sleep apnea who presents secondary to difficulty breathing.   History obtained from combination of chart review and from patient. Presented with difficulty breathing, heaviness in chest, and shortness of breath starting yesterday morning. Felt unwell on Thursday but unable to specify symptoms. Reports a dry cough and a desire to cough but fear of not being able to breath as a result. Reports rhinorrhea in setting of allergies.  Endorses throat discomfort and painful swallowing started yesterday afternoon attempted to soothe with honey in tea.  Now has a hoarse voice.  Reports chronic diarrhea, but no recent worsening. Patient with stomach discomfort for more than two weeks, described as a burning sensation.  Previous medication (Omeprazole) and probiotics were ineffective. No changes in urination. No nausea or vomiting. Occasionally breaks out in sweats. No recent chills. Has fatigue and weakness after bowel movements in the morning, takes diarrhea medicine and tries to nap. No known exposure to COVID-19.  Of note, patient desaturated to 88% on scene and placed on 10 L nonrebreather with improvement of SpO2 to 97% with EMS.   Hospital Course and Significant Findings: COVID-19 DISEASE (5/31/2022)  ACUTE HYPOXEMIC RESPIRATORY FAILURE (6/3/2022)  PNEUMONIA- had sob qith hypoxia requiring up to 4 L of oxygen, on day of discharged was able to walk with PT and not desaturate nor have any sob symptoms. Symptoms due to covid + superimposed pneumonia. Had IV abx, steroids and remdesivir as inpatient. Had diarrhea, likely due to covid. -complete course of prednisone -complete one week of abx with vantin, doxycycline -mucinex and flonase for congestion    HTN (HYPERTENSION) (1/27/2012)   Plan: continue labetalol and lisinopril   OSTEOARTHRITIS (2/10/2012)   Plan: mobic prn   HYPERLIPIDEMIA (7/15/2012)  ATHEROSCLEROSIS OF AORTA (11/22/2017)   Plan: statin    BENIGN ESSENTIAL TREMOR (1/14/2014)  RESTLESS LEGS SYNDROME (6/13/2017)   Plan: primidone   OBSTRUCTIVE SLEEP APNEA (2/10/2014)   Assessment/plan: Noted.  Not on cpap at home     GERD (GASTROESOPHAGEAL REFLUX DISEASE) (2/20/2015)   Plan: PPI and carafate   RIGHT NORMAL TENSION GLAUCOMA, MILD STAGE (7/28/2015)   Plan: continue home drops   DM 2 (9/26/2016) -diet controlled at home   Complications: none   Primary Procedures:  none   Secondary Procedures:  None   Imaging:   Narrative/Impressions of Imaging Results for 30 Days XR CHEST   Result Date: 12/1/2023     SINGLE AP PORTABLE CHEST RADIOGRAPH     ** HISTORY **:  Dyspnea.     COMPARISON: 5/12/2023.     ** FINDINGS **:  The lung volumes are within normal limits. Bibasilar opacities likely represent atelectasis. A small left pleural effusion is likely. There is no pneumothorax. The heart is normal in size. Pulmonary vascular redistribution is visible. Atherosclerotic calcifications of the thoracic aorta are seen.  The visualized bones remain intact.       1. Likely small left pleural effusion.  2. Aortic atherosclerosis.             Consults: HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION.   Condition on Discharge:  stable   Subjective: No sob, doe, cough, fevers, chills   Physical Exam:  BP 166/57  | Pulse 52  | Temp 97.1 °F (36.2 °C)  | Resp 18  | Wt 82.3 kg (181 lb 7 oz)  | SpO2 93%  | Breastfeeding No  | BMI 33.19 kg/m²    Gen: WN/WD, No Apparent Distress, Alert and Oriented HEENT: NC, AT, No scleral icterus, Moist Mucosal Membranes Neck: No elevated JVP or JVD, no bruits, no lymphadenopathy, no thyromegaly Lungs: Clear to Auscultation Bilaterally, no wheezing Cards: Regular Rate and Rhythm Abd: Soft, Non-Tender to palpitation, Non-Distended Ext: no edema Psych: Normal affect and mentation Neuro: CN II-XII grossly intact, moving all extremities, no cerebellar signs, no gross neurological deficits  MSK: Joints WNL Skin: warm and dry, no rashes, capillary reflex normal    Code Status at Time of Discharge: Full Code   Smoker: No.   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   All medication recommendations, lifestyle changes, referrals, and follow up appointments that pertain to this hospitalization and other pertinent medical conditions were discussed in detail and at length with patient on the date of discharge. All questions answered and concerns addressed.     -left voicemail for dtr       MD 12/4/2023 1:41 PM         Note Details  Author (M.D.) File Time 12/4/2023  1:46 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 12/1/2023  ED to Hosp-Admission (Discharged) on 12/1/2023  ED to Hosp-Admission (Discharged) on 12/1/2023   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  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  RIGHT NORMAL TENSION GLAUCOMA, MILD STAGE  DM 2  RESTLESS LEGS SYNDROME  ATHEROSCLEROSIS OF AORTA  COVID-19 DISEASE  OSTEOARTHRITIS  BENIGN ESSENTIAL TREMOR  ACUTE HYPOXEMIC RESPIRATORY FAILURE Care Timeline  12/01   Admitted from ED (Observation) 1922 12/03   Admitted 1020 12/04   Discharged 1900  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/4/2023) Medication List at Discharge   acetaminophen 1,000 mg Oral EVERY 6 HOURS AS NEEDED  atorvastatin calcium 40 mg Oral EVERY BEDTIME  brimonidine tartrate 0.2 % INSTILL 1 DROP INTO Right eye 2 times daily.  cefpodoxime proxetil 200 mg Oral 2 TIMES A DAY WITH MEALS  doxycycline monohydrate 100 mg Oral 2 TIMES A DAY  fluticasone propionate 50 mcg/actuation Instill 1 spray in each nostril daily  guaifenesin 600 mg Oral EVERY 12 HOURS AS NEEDED  labetalol HCl 200 mg Oral 2 TIMES A DAY  latanoprost 0.005 % 1 Drop Both eyes EVERY BEDTIME, for Glaucoma  lisinopril 20 mg Oral DAILY  meloxicam 7.5 mg Oral DAILY AS NEEDED, . Take with food  multivitamin 1 tablet Oral DAILY  pantoprazole sodium 40 mg Oral 2 TIMES A DAY  prednisone 40 mg Oral DAILY  primidone 25 mg Oral DAILY  sodium chloride 0.65 % 2 Sprays Each nostril EVERY 2 HOURS AS NEEDED  sucralfate 1 gram Take 1 tablet by mouth 4 times a day . Note: If desired, dissolve tablet in 20 mL of water to make a slurry mixture and take the entire dose.