Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Cardiac pacemaker insertion, Cellulitis, Drug use disorder, Hypertension, Intensive care
Clinical narrative: Date of Admission: 11/30/2023   Date of Discharge: 12/7/2023   Issues to be Addressed at Follow-up: 1.  Transition from methadone to buprenorphine patient will follow-up with facility.  Please refer to Dr. note for detailed consultation. 2.  Cardiology follow-up regarding permanent pacemaker and med titration.   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/2/2023  4:42 PM BLOOD CULTURE 2 Preliminary BLOOD   12/2/2023  4:37 PM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SYNCOPE   ? CHRONIC PAIN       Patient with opioid use disorder.  Gets methadone from facility.    Unsafe to give additional opioids for pain control.    Lumbar pain; hx of MVA-       ? CELLULITIS   ? CARDIAC ARREST DUE TO UNDERLYING CARDIAC CONDITION   ? ACQUIRED LONG QT SYNDROME       Torsades rel cardiac arrest in setting of bradycardia while on multiple QT prolonging medications (methadone and pregabalin) Dec 2023   ? FALL RISK   ? COVID-19 DISEASE   ? OBSTRUCTIVE SLEEP APNEA       Date: 7/29/2020  Study Type: WatchPAT  pAHI: 98.6  BMI: 43.06  Min SpO2: 83% SpO2<90%: 20.5 minutes  Severe Sleep Apnea. Tx: ResMed ASV (Adaptive Servo-Ventilation)  NOTE: For patients on ASV for OSA, monitor for signs of CHF.  If LVEF < 45%, stop ASV and consider a repeat in-lab titration at that point with a modality such as bi-level PAP ST.   ? ATRIAL FIBRILLATION, UNSPECIFIED   ? PANIC DISORDER   ? OPIOID MEDICATION AGREEMENT LETTER   ? PREMATURE VENTRICULAR BEATS   ? HX OF HEPATITIS C       Genotype 1a   ? HTN (HYPERTENSION)     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 68 yo M with history hep C, AF, HTN, OSA with evening BiPAP, BPH, severe obesity, chronic pain on methadone, anxiety with panic attacks, prior reported bradycardia who initially presented on 11/30 after being transferred from Medical Center for syncope.  On 12/1 patient developed slow AF and went to VF resulting in CODE BLUE.  ROSC was achieved (shockx3 and CPR, lasting about 15 min) and patient was placed on Levophed.  Telemetry review revealed slow AF inducing torsades followed by VT/VF arrest.  Cordis was placed by ICU physician and temporary transvenous pacer was initiated.  Patient was eventually extubated on 12/3 and single-chamber pacemaker was inserted on the evening of 12/5.    Patient did well overnight and cardiology cleared to discharge on 12/6.  I kept patient in additional day to formulate a plan regarding opiate withdrawal management.  After discussing case in detail with Dr., who saw patient on the day of discharge, it was decided that patient will start on a lower dose of methadone and rapidly titrate down as he transitions to buprenorphine.  Patient was offered to stay in the hospital on high-dose, short acting opiates equivalent to methadone and titrate down from there but patient refused.  Patient understood the risk and the benefits of restarting methadone, albeit a lower dose.  He also understands that he must titrate off methadone for Is a candidate to mitigate risk of torsades and cardiac arrest.  Patient showed understanding QT prolongation and he has a clear understanding of these risks.  Patient will follow-up closely with facility to act out this plan.   Of note, I discharge patient with an additional 4 days of Vantin to treat cellulitis on his arm.  Patient will follow-up with device clinic next week and follow-up with cardiology/PCP for med titration.   Primary Procedures:  Procedure(s): CARDIAC PACEMAKER INSERTION PERMANENT INTRAVENOUS   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Cardiac arrest due to torsades secondary to long-term methadone use   Complications: none   Consults:  CARDIOLOGY - INITIAL INPATIENT CONSULTATION. CARDIOLOGY - ONGOING INPATIENT CONSULTATION. CHEM DEPENDENCY REHAB PROGRAM - INITIAL INPATIENT CONSULTATION. CHEM DEPENDENCY REHAB PROGRAM - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code   DO  12/7/2023 3:11 PM         Note Details  Author (D.O.) File Time 12/7/2023  3:11 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine  Admit Date 11/30/2023  Admission (Discharged) on 11/30/2023  Admission (Discharged) on 11/30/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  COLONOSCOPY SCREENING Noted 9/26/2023 CARDIAC PACEMAKER INSERT From 12/1/2023 to 12/7/2023  Hospital Problem List   HTN (HYPERTENSION)  PANIC DISORDER  ATRIAL FIBRILLATION, UNSPECIFIED  OBSTRUCTIVE SLEEP APNEA  SYNCOPE  HX OF HEPATITIS C  PREMATURE VENTRICULAR BEATS  OPIOID MEDICATION AGREEMENT LETTER  FALL RISK  COVID-19 DISEASE  ACQUIRED LONG QT SYNDROME  CARDIAC ARREST DUE TO UNDERLYING CARDIAC CONDITION  CELLULITIS  CHRONIC PAIN Care Timeline  12/01   Admitted 0845 12/05   CARDIAC PACEMAKER INSERTION PERMANENT INTRAVENOUS 12/07   Discharged 2143  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 12/7/2023)   Discharge Orders  BUN  CREATININE W GFR, CALCULATED  BICARBONATE  CHLORIDE  GLUCOSE  POTASSIUM  SODIUM Medication List at Discharge   bisacodyl 5 mg Take 2 tablets by mouth one time  at 4 pm on the day before procedure  buprenorphine HCl 1 mg Sublingual DAILY  cefpodoxime proxetil 200 mg Oral 2 TIMES A DAY, For arm cellulitis.  diclofenac sodium 0.1 % 1 Drop Left eye 4 TIMES A DAY  dorzolamide HCl/timolol maleat 22.3-6.8 mg/mL 1 Drop Both eyes 2 TIMES A DAY, for Glaucoma  gatifloxacin 0.5 % INSTILL 1 DROP INTO OPERATED EYE(S) 4 TIMES A DAY AS DIRECTED BY PHYSICIAN  lisinopril 5 mg Take 1 tablet by mouth daily (DO NOT TAKE UNTIL FURTHER INSTRUCTED BY CARDIOLOGIST OR PRIMARY DOCTOR.)  metoprolol succinate 50 mg Oral DAILY  peg3350/sod sulf,bicarb,Cl/KCl 240-22.72-6.72 -5.84 gram Add water to fill line and shake until dissolved. Day before procedure: at 6pm drink 8 ounces every 15 minutes until 2 liters are consumed. 5 hours before procedure: drink the remaining 2 liters (8 ounces every 15 minutes). Finish at least 3 hours before scheduled arrival time  prednisolone acetate 1 % 1 Drop Right eye 4 TIMES A DAY  sertraline HCl 125 mg Oral DAILY  terazosin HCl 10 mg Oral EVERY BEDTIME  warfarin sodium 2.5 mg Take by mouth as directed by Anticoagulation service