Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Diarrhoea, Dysphagia, Gastrooesophageal reflux disease, Hyperglycaemia, Imaging procedure abnormal
Clinical narrative: Discharge Summary MD (Physician)  Hospitalist Physician Discharge Summary   Age: 68 y.o. Admit Date: 8/13/2022 12:51 PM Discharge Date:  8/18/22 Admitting Physician:  Discharge Physician: APRN / MD    Discharge Diagnosis: Principal Problem:   Pneumonia due to infectious organism Active Problems:   AKI (acute kidney injury)   Other dysphagia   GERD (gastroesophageal reflux disease)   Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin       HPI: Patient is a 68 y.o. female with a history  below presenting with complaints of cough, fever since Tuesday. Mild confusion with this. Not sure what makes his symptoms better or worse. Not able to cough anything up. Associated dysphagia. Denies any chest pain, abdominal pain or any other concerning symptoms. Imaging with the right lower lobe pneumonia. Admitted for further evaluation.   Hospital Course: patient admitted with pneumonia. History of dysphagia. Seen by speech and is s/p barium swallow with likely esophageal spasms. GI was consulted. She was started on cardizem. She has AKI which has improved. Patient developed diarrhea which has also improved. She will DC home to complete abx.    * Pneumonia due to infectious organism Continue azithromycin, Augmentin.  IS and acapella. ACM on DC for close f/u. On 2L NC, does not wear home O2. Wean as tolerated. Ambulatory spO2 prior to DC.   Dysphagia - ? Esophageal spasms on barium.  GI following.     Acute kidney injury - improving with IVF   DM - SSI, glucoscans.   Anemia - no overt bleeding. Monitor daily labs.    Diarrhea-improving   GI/DVT ppx - PPI.  Heparin subQ. Home with spouse on DC       Physical Exam on the Date of Discharge: Physical Exam Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert.         Consults:   IP CONSULT TO SEPSIS NURSE NAVIGATOR IP CONSULT TO GASTROENTEROLOGY   Significant Diagnostic Studies:      CT Chest Pulmonary Embolism W Contrast Results  Status: Final result (Exam End: 8/13/2022 16:38)       Order Report   Order Details         Study Result    Narrative & Impression PROCEDURE INFORMATION:  Exam: CTA Chest With Contrast  Exam date and time: 8/13/2022 4:30 PM  Age: 68 years old  Clinical indication: Cough and shortness of breath and other: Covid; Patient  HX: Pe suspected. HX, hyst, HTN, pulm nodes  TECHNIQUE:  Imaging protocol: Computed tomographic angiography of the chest with contrast.  3D rendering (Not supervised by radiologist): MIP and/or 3D reconstructed  images were created by the technologist.  Radiation optimization: All CT scans at this facility use at least one of these  dose optimization techniques: automated exposure control; mA and/or kV  adjustment per patient size (includes targeted exams where dose is matched to  clinical indication); or iterative reconstruction.  Contrast material: ISOVUE 370; Contrast volume: 100 ml; Contrast route:  INTRAVENOUS (IV);   COMPARISON:  CR XR PORTABLE CHEST 8/13/2022 1:53 PM  FINDINGS:  Pulmonary arteries: Normal. No pulmonary emboli.  Aorta: Unremarkable. No aortic aneurysm. No aortic dissection.  Lungs: Consolidation in the right lower lobe with ground-glass opacities.  Several small 3 mm ground-glass nodule are seen in the right mid lung. Mild  linear opacities in the left lower lung.  Pleural spaces: Unremarkable. No pneumothorax. No pleural effusion.  Heart: Unremarkable. No cardiomegaly. No pericardial effusion.  Lymph nodes: Unremarkable. No enlarged lymph nodes.  Bones/joints: Unremarkable. No acute fracture.  Soft tissues: Unremarkable.  IMPRESSION IMPRESSION:  1. No pulmonary embolism.  2. Consolidation in the right lower lobe with ground-glass opacity suspicious  for infection or aspiration. Mild linear opacities in the left lower lung may  represent atelectasis.  3. Several tiny nonspecific 3 mm pulmonary nodules are seen in the right mid  lung. Recommend CT Chest at 3-6 months. If stable, then consider CT Chest at 2  years and 4 years.     XR Barium Swallow/ Esophagus