Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Pneumothorax, Presyncope, SARS-CoV-2 test positive, Wound
Clinical narrative: Date of Admission: 9/25/2023   Date of Discharge: 9/30/2023   Issues to be Addressed at Follow-up: Comfortable on hospice   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/31/2023 to 10/1/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) DIARRHEA   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? ANEMIA   ? HYDROPNEUMOTHORAX   ? HYPERTRIGLYCERIDEMIA       Trigs = 256 on 8/3/2021   ? HYPERPARATHYROIDISM, UNSPECIFIED       PTH = 171   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? COVID-19 DISEASE   ? ADENOCARCINOMA COLON, UNSPECIFIED SITE       Added automatically from request for surgery 1153402   ? ATHEROSCLEROSIS OF AORTA       CT abd pelvis 12/4/2021   ? HTN (HYPERTENSION)   ? OBSTRUCTIVE SLEEP APNEA       Date: 11/14/2017  Study Type: WatchPAT  pAHI: 12.8 (<5 normal) BMI: 35.11   ESS: 11  Min SpO2: 91% SpO2<90%:  0 minutes Mild Sleep Apnea.      Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Hospice   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 76-year-old male with past medical history significant for colon cancer on chemotherapy, OSA, hypertension, hypertriglyceridemia, GERD, hyperparathyroidism who presents emergency department with presyncopal episode, acute kidney injury, diarrhea, and positive for COVID.  Pt hydrated and loose stools improved.  Pt feels that it is time to start hospice and he is ready to die.  Pt discharged to hospice.     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Diarrhea, likely chemo induced.   Complications: none   Consults:  PALLIATIVE CARE - INITIAL INPATIENT CONSULTATION. PALLIATIVE CARE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR     Note Details  Author (M.D.) File Time 9/30/2023  1:45 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Critical Care Medicine  Admit Date 9/25/2023  ED to Hosp-Admission (Discharged) on 9/25/2023  ED to Hosp-Admission (Discharged) on 9/25/2023   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)  ATHEROSCLEROSIS OF AORTA  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  HYPERPARATHYROIDISM, UNSPECIFIED  HYPERTRIGLYCERIDEMIA  DIARRHEA  OBSTRUCTIVE SLEEP APNEA  ADENOCARCINOMA COLON, UNSPECIFIED SITE  COVID-19 DISEASE  HYDROPNEUMOTHORAX  NONTRAUMATIC ACUTE KIDNEY INJURY  ANEMIA Care Timeline  09/26   Admitted from ED (Observation) 0850 09/30   Discharged 1155  Discharge   Home with Hospice   Discharge Instructions (AVS) (Printed 9/30/2023) Medication List at Discharge   acetaminophen 650 mg Rectal EVERY 6 HOURS AS NEEDED  albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply for asthma is 1 canister  alcohol antiseptic pads Use as directed for maintaining pneumostat device  amlodipine besylate 5 mg Oral DAILY  hydrophilic cream Apply to affected area(s) as needed (wound on back side) If patient is frequently incontinent, pls discontinue dressing order to coccyx. . Instead, apply Triad to wound bed prn incontinence.  loperamide HCl 2 mg Take 2 tablets by mouth at the first onset of diarrhea, then 1 tablet by mouth every 2 hours around the clock until diarrhea-free for at least 12 hours. During the night, may take 2 tablets by mouth every 4 hours. Maximum of 8 tablets per day.  omeprazole Oral  prochlorperazine 25 mg Rectal EVERY 12 HOURS AS NEEDED