Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Gastrointestinal oedema, Glycosylated haemoglobin increased, Helicobacter test, Hepatic steatosis
Clinical narrative: Date of Admission  12/28/2021   Date of Discharge  01/07/2022   Reason for Hospitalization   dx with covid on 12/26. pt recieved infusion on 12/26. pt reports increased weakness, malaise, fatigue, intermittant cp  Hospital Course       Pt is a 77 y.o. M with pmh HTN, T2DM, HLD, CAD (with 7 stents) and recent UTI with nonobstructing renal calculi on CT abdomen presenting to ED with ongoing nausea and sob after recently testing positive for COVID-19. CXR w/ bilateral opacities, inflammatory markers all elevated consistent with COVID infection. Started on dexamethasone. CT chest PE protocol with no evidence of PE, moderate interstitial edema, small B/L pleural effusions. Given edema and pleural effusions, echo ordered and showing new onset HFrEF with EF 40% and global hypokinesis. Hospital course complicated by episode of abdominal pain and lethargy with elevated lactate/crp with stat CT abdomen no acute findings aside from b/l pleural effusions and diffuse mesenteric edema, hyperglycemia/uncontrolled DM2 requiring insulin drip briefly. Continued on empiric antibiotics, weaning off supplemental (2-4L) oxygen as able.  Patient continued to appear nonseptic without significant fever, leukocytosis, thus antibiotics were discontinued on 1/3.  His dexamethasone was additionally discontinued on 1/3 as patient was now on room air and continue to struggled with uncontrolled hyperglycemia.  Lantus is periodically increased from 10 units to 30 units nightly with sliding scale and carb correction insulin.  Chlorpromazine added for hiccups at night appears to have uncontrolled.  Due to persistently elevated LFTs and alkaline phosphatase there was concern over possible hepatobiliary pathology.  Right upper quadrant ultrasound revealed biliary sludge and hepatic steatosis without acute abnormalities.  Transaminitis presumed like secondary to multifactorial effect of high Lipitor dose, acute COVID-19 pathology and less contributory biliary sludge.  His abdominal pain continues to be improved on aggressive bowel regimen of Doc senna, MiraLAX with as needed enemas and suppositories.  Patient's wife expressed concerns over patient's current endocrinologist and requested follow-up with  physicians patient.  We will additionally schedule outpatient gastric emptying study.  Discharge Diagnoses      1. Pneumonia due to COVID-19 virus   2. AKI (acute kidney injury)   3. Diabetes mellitus   Constipation  Type diabetes  Functional Abdominal Pain  Other Diagnoses   Ongoing  No qualifying data  Historical  No qualifying data      Pending Labs  H pylori Stool Antigen (Dispatched, Ordered 01/04/2022, 13:20)   Discharge Disposition  Skilled Nursing Facility    Medications  New, Changed, or Refilled Medications  aspirin (aspirin 81 mg , chewable) 81 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    atorvastatin (atorvastatin 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    insulin detemir (insulin detemir (LEVEMIR) 100 un 30 units, Subcutaneous, At Bedtime, 15 mL, 0 Refill(s)    insulin lispro (insulin lispro 100 units/mL injec 1-8 units, Subcutaneous, tid w/Meals, << Sliding Scale Comments >>  150 - 174   1 units Call if less than 80  175 - 199   2 units   200 - 224   3 units   225 - 249   4 units   250 - 274   5 units   275 - 299   6 units   300 - 324   7 units   325 - 349   8  Instructions:<< Sliding Scale Comments >>150 - 174   1 units Call if less than 80175 - 199   2 u  pantoprazole (pantoprazole 40 mg oral delayed rel 40 mg, 1 Tablet(s), Oral, bid, for 30 day(s), 40 mg BID for 1 month, then 40 mg daily, 60 Tablet(s), 0 Refill(s)  Instructions:40 mg BID for 1 month, then 40 mg daily    Medications to be Continued  Misc. Medication (BD UF SHORT PEN NEEDLE 8MMX31G) 0 Refill(s)    Misc. Medication (BD UF SHORT PEN NEEDLE 8MMX31G) 0 Refill(s)    carvedilol (carvedilol 3.125 mg) 0 Refill(s)    clopidogrel (clopidogrel 75 mg) 0 Refill(s)    furosemide (furosemide 20 mg) 0 Refill(s)      Discontinued Medications  glimepiride (glimepiride 4 mg) 0 Refill(s)    omeprazole (omeprazole 40 mg oral delayed release 0 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 37.1 °C  TMIN: 36.9 °C  TMAX: 37.3 °C  HR: 107  RR: 16  BP: 125/74  SpO2: 93%      General: Alert and oriented x3. No acute distress.  Eye: Pupils are equal, round and reactive to light.  HENMT: Normocephalic, Normal hearing, Oral mucosa is moist.  Neck: Supple, No jugular venous distention.  Respiratory: Lungs are clear to auscultation, Respirations are non-labored  Cardiovascular: Normal peripheral perfusion, Heart regular rate and rhythm.  Gastrointestinal: Soft, nontender, Normal bowel sounds.  Neurologic: Alert, Oriented, No focal defects.  Psychiatric: Cooperative, Appropriate mood & affect.  Time Spent  45 minutes   Follow Up Appointments     Follow Up Appt Medicine Endocrinology, Clinic Name/Phone: Diabetes/Endocrinology Clinic, Provider Name: NO , PREFERENCE, Within 14 Days, No tests, Comments Poorly controlled DM, unhappy with external endocrinologist, A1C 11.9%    Nursing/Other Orders  Patient Information  Patient:      Age: 77 Years  Sex: Male  DOB:   Admit Date:  12/28/2021        Discharge Date:  01/07/2022   Visit Information  Attending Provider:  Accepting Physician and Facility Name: Dr.   Primary Care Provider: MD  Health Status  Discharge Diagnosis  Diagnoses: 1:Pneumonia due to COVID-19 virus; 2:AKI (acute kidney injury); 3:Diabetes mellitus; CAD (coronary artery disease); HLD (hyperlipidemia); HTN (hypertension)  Vital Signs at Discharge Vital Signs (midnight yesterday to current) Parameter                    Last Charted  Minimum  Maximum                          Temperature                      37.1      (01/07 08:57) 36.6      (01/06 08:00) 37.3      (01/06 16:00)  Heart Rate                      107       (01/07 08:57) 77        (01/06 16:00) 113       (01/07 04:04)  Resp Rate                      16        (01/07 04:04) 16        (01/07 04:04) 18        (01/06 16:00)  NIBP                      125/74    (01/07 08:57) 125/74    (01/07 08:57) 166/86    (01/06 16:00)  SpO2                      93        (01/07 08:57) 93        (01/07 08:57) 96        (01/07 04:04)  Pain Score                      0         (01/07 10:00) 0         (01/07 10:00) 8         (01/06 08:30) Post-Discharge Orders  Physical Therapy Evaluate and treat  Weight-Bearing Full weight bearing  Occupational Therapy Evaluate and treat  Speech Therapy None  Diet Supplement/Additive - Adult :  01/07/22 12:30:00, Boost High Protein, Vanilla | Magic Cups, Oral, boost with breakfast and supper, vanilla magic cup with lunch Supplement/Additive - Adult :  01/03/22 14:07:00, Boost High Protein, Vanilla | Magic Cups, tid w/Meals, Oral, boost with breakfast and supper, vanilla magic c Supplement/Additive - Adult :  01/08/22 7:30:00, Boost High Protein, Vanilla | Magic Cups, Oral, boost with breakfast and supper, vanilla magic cup with lunch Supplement/Additive - Adult :  01/07/22 17:30:00, Boost High Protein, Vanilla | Magic Cups, Oral, boost with breakfast and supper, vanilla magic cup with lunch Regular Diet :  Ordered on 12/29/21 1:06:00, Meal Start Time Breakfast 0700 to 0900  Additional Orders:   Outpatient follow up to establish care with endocrinology  Outpatient follow up with PCP with repeat CMP  Outpatient gastric emptying study  Discharge Medications New, Changed, or Refilled Medications  aspirin (aspirin 81 mg , chewable) 81 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    atorvastatin (atorvastatin 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    insulin detemir (insulin detemir (LEVEMIR) 100 un 30 units, Subcutaneous, At Bedtime, 15 mL, 0 Refill(s)    insulin lispro (insulin lispro 100 units/mL injec 1-8 units, Subcutaneous, tid w/Meals, << Sliding Scale Comments >>  150 - 174   1 units Call if less than 80  175 - 199   2 units   200 - 224   3 units   225 - 249   4 units   250 - 274   5 units   275 - 299   6 units   300 - 324   7 units   325 - 349   8  Instructions:<< Sliding Scale Comments >>150 - 174   1 units Call if less than 80175 - 199   2 u  pantoprazole (pantoprazole 40 mg oral delayed rel 40 mg, 1 Tablet(s), Oral, bid, for 30 day(s), 40 mg BID for 1 month, then 40 mg daily, 60 Tablet(s), 0 Refill(s)  Instructions:40 mg BID for 1 month, then 40 mg daily    Medications to be Continued  Misc. Medication (BD UF SHORT PEN NEEDLE 8MMX31G) 0 Refill(s)    Misc. Medication (BD UF SHORT PEN NEEDLE 8MMX31G) 0 Refill(s)    carvedilol (carvedilol 3.125 mg) 0 Refill(s)    clopidogrel (clopidogrel 75 mg) 0 Refill(s)    furosemide (furosemide 20 mg) 0 Refill(s)      Discontinued Medications  glimepiride (glimepiride 4 mg) 0 Refill(s)    omeprazole (omeprazole 40 mg oral delayed release 0 Refill(s)    Discharge to Facility:  Further orders to be followed by the patient's PCP or other supervising physician at facility.        Addendum on January 20, 2022 18:02:52 (Verified)    Attestation on January 20, 2022 18:03 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions: