Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Blood urea increased, Breath sounds abnormal, COVID-19, Carbon dioxide normal, Chest X-ray abnormal
Clinical narrative: Age: 75 y.o. Admit Date: 7/27/2022 11:36 AM Discharge Date:  8/7/2022 Admitting Physician: Dr.  Discharge Physician: MD   Discharge Diagnosis: Principal Problem:   Gastrointestinal hemorrhage with melena Active Problems:   Essential hypertension   Paroxysmal A-fib   COVID-19 virus detected   CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission, "The patient is a ,75 y.o. female known to have a background history of paroxysmal A fibrillation, chronic kidney disease, anemia, history of endometrial cancer in the past, presented on 7/27/2022 with    Nausea as well as melena-as per history given by family patient was having worsening black stools that started 2 weeks back and also complaining of abdominal discomfort. She was also positive for covid  from last one week and not complaining of any productive cough or shortness of breath. Seems to be weak and debilitated. Has nausea as well as vomiting associated with that. Not on any but the nurse. Patient says blood loss is mild-to-moderate and family thinks that she is losing blood from a long time and had received blood transfusions in the past. On oral anti-coagulation. History of gastric bypass as well and follows with GI as an outpatient. Hemoglobin on the lower side. Will be admitted for further evaluation"     Hospital Course: Patient, is a 75 y.o. female who presented with melena.  She was managed for the following:   * Gastrointestinal hemorrhage with melena Acute blood loss anemia - Patient presented with melena.  GI was consulted and performed EGD, showed ulceration at Roux en Y anastamosis.  Will continue protonix BID, carafate. Hgb improved s/p transfusion RBCs, remained stable.  Follow-up with GI outpatient.     COVID-19 infection - incidentally positive on 7/27.  Patient was stable on room air, no hypoxia.  Vaccinated.  D-dimer was mildly elevated to 600s.  BLE US negative for DVT.  CT PE study negative for PE; shows possible early pneumonia and emphysema.     Pneumonia - CT PE study showed bilaterally infiltrates possible early pneumonia.  She was treated with antibiotics, improved.  She had a productive cough that improved.     Acute UTI - symptomatic with dysuria.  Urine culture grew Pseudomonas.  Intermediate to merrem.  Discussed with pharmacy, based on sensitivities, she was given tobramycin x 1 dose to complete treatment for simple cystitis.     Paroxysmal Afib -    Continue flecainide, metoprolol.  Evaluated by cardiology, recommended to remain off eliquis on discharge due to GIB.  Consider outpatient Watchman.  Follow-up with cardiology outpatient.     Vertigo - hx Meniere's disease, has outpatient tympanic membrane injections with Dr. Will need close outpatient follow-up.    Low normal blood pressure - low normal range, 90/50s; chronic per patient.  Asymptomatic  Debility - PT consulted. Patient was discharged to SNF.           Physical Exam on the Date of Discharge: Blood pressure (!) 95/58, pulse 89, temperature 97.5 °F (36.4 °C), temperature source Oral, resp. rate 18, height 5' 2" (157.5 cm), weight 73.4 kg (161 lb 13.1 oz), SpO2 95 %. General - NAD, appears stated age, frail elderly female HEENT - EOMI, PER, MMM,  Chest - lungs clear bilaterally, , normal effort Heart - RRR, NS1S2,  Abdomen - Soft, non-tender, n  Extremities - no edema Psych - AAOx3, affect appropriate Skin - dry   Discharge Condition: improved   Disposition: SNF   CONSULTS DURING ADMISSION:  IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO CARDIOLOGY   IMAGING / PROCEDURES / RESULTS:     XR Portable Chest   Result Date: 7/27/2022                         Medical Center                                                                   Radiology  PATIENT NAME:                  MR#:   PROCEDURE DATE:  07/27/2022                       ACCOUNT#:  ACCESSION #:  ROOM#:  31 ORDERING PHYS:  EXAM: Portable chest x-ray   CLINICAL INDICATION:Abnormal breath sounds   TECHNIQUE:Portable AP view of the chest   COMPARISON: 07/26/2022   FINDINGS:No focal airspace disease or pulmonary edema.  Stable cardiac contours without dilatation.  No pneumothorax or pleural effusion.   IMPRESSION: No convincing airspace disease or pulmonary edema.               THIS IS AN ELECTRONICALLY VERIFIED REPORT             7/27/2022 12:47 PM:  MD   MD:  07/27/2022 TD:  07/27/2022 JOB #:                                       Radiology Page 1    of   1                                                          COPY   XR Portable Chest   Result Date: 7/26/2022                         Medical Center                                                                  Radiology  PATIENT NAME:                  MR#:  PROCEDURE DATE:  07/26/2022                       ACCOUNT#:  ACCESSION #:                              ROOM#:  ORDERING PHYS:  EXAM:  Chest radiograph, 1 view.  INDICATION:  COVID.  COMPARISON:  Prior radiographs, most recent dated 12/29/2014.  TECHNIQUE:  Portable AP view of the chest.  FINDINGS:  Cardiomediastinal silhouette is unchanged in size and configuration.  Pulmonary vasculature is within normal limits.  Lungs are hyperinflated but appear clear.  No focal consolidation.  No pneumothorax or significant pleural effusion.  There are extensive chronic or degenerative osseous changes which appear greatest at the right shoulder.  No definite acute osseous abnormality.  IMPRESSION:  Chronic changes without definite acute cardiopulmonary process.               THIS IS AN ELECTRONICALLY VERIFIED REPORT               7/26/2022 11:23 AM:  MD   MD:  07/26/2022 :  07/26/2022 JOB #:  Radiology Page 1    of   1                                                          COPY   CT Chest Pulmonary Embolism W Contrast   Result Date: 8/2/2022 PROCEDURE INFORMATION: Exam: CTA Chest With Contrast Exam date and time: 8/2/2022 8:58 PM Age: 75 years old Clinical indication: Cough, SOB, and covid (+). HX: SVT and PAF. 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: 62 ml; Contrast route: INTRAVENOUS (IV);  COMPARISON: CR XR PORTABLE CHEST 7/27/2022 12:15 PM FINDINGS: Pulmonary arteries: Normal. No pulmonary emboli. Aorta: Unremarkable. No aortic aneurysm. No aortic dissection. Lungs: Significant centrilobular emphysema with bibasilar atelectasis, and possible early RLL infiltrate/pneumonia with small bilateral pleural effusions. No mass. Pleural spaces: No pneumothorax. Small bilateral pleural effusions. Heart: No cardiomegaly. No pericardial effusion. Moderate coronary artery calcification. Lymph nodes: Unremarkable. No enlarged lymph nodes. Diaphragm: Moderate size hiatal hernia. Bones/joints: No acute fracture.  Moderate spondylosis.  Osteopenia. Soft tissues: Unremarkable.    IMPRESSION: 1. No pulmonary embolism or acute cardiac or aortic abnormalities. 2. Significant centrilobular emphysema with bibasilar atelectasis, and possible early RLL infiltrate/pneumonia with small bilateral pleural effusions. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 08/02/2022 10:08 PM   US Lower Ext Venous Bilateral   Result Date: 8/2/2022                         Medical Center                                                                    Radiology  PATIENT NAME:                   MR#:   PROCEDURE DATE:  08/02/2022                       ACCOUNT#:   ACCESSION #:                               ROOM#:   ORDERING PHYS:  EXAM:  Venous Doppler ultrasound dated  08/02/2022.  CLINICAL INDICATION: COVID positive.  Elevated D-dimer.  PROCEDURE: Real time and doppler evaluation of the bilateral lower extremity were done.  COMPARISON: None.  FINDINGS: There is normal doppler venous flow and compressibility of the common femoral, superficial femoral, and popliteal veins.  There is no evidence of intraluminal echogenic material to suggest deep vein thrombosis.  IMPRESSION:  No evidence of DVT in the bilateral lower extremity.                 THIS IS AN ELECTRONICALLY VERIFIED REPORT              8/2/2022 11:34 AM:  MD   MD:  08/02/2022 TD:  08/02/2022 JOB #:  Radiology Page 1    of   1                                                          COPY     Procedure(s): EGD /C BIOPSY (N/A)       LABS AT TIME OF DISCHARGE:   Lab Results Component Value Date   WBC 9.1 08/07/2022   HGB 9.1 (L) 08/07/2022   HCT 26.8 (L) 08/07/2022   MCV 92.4 08/07/2022     Lab Results Component Value Date   SODIUM 142 08/07/2022   POTASSIUM 3.9 08/07/2022   MAGNESIUM 1.5 (L) 07/27/2022   PHOSPHORUS 4.1 03/22/2022   CHLORIDE 108 08/07/2022   CO2 26 08/07/2022   GLUCOSE 76 08/07/2022   BUN 24 08/07/2022   CREATININE 1.4 (H) 08/07/2022   CALCIUM 8.2 (L) 08/07/2022   TBILIRUBIN 0.2 08/07/2022   DBILIRUBIN 0.3 (H) 12/31/2008   ALP 34 (L) 08/07/2022   AST 11 08/07/2022   ALBUMIN 2.9 (L) 08/07/2022     Lab Results Component Value Date   INR 1.1 07/27/2022     Microbiology Results (last 14 days)    Procedure Component Value Units Date/Time   Urine Culture   (Abnormal)  (Susceptibility) Collected: 08/02/22 1053   Order Status: Completed Specimen: Reflexed from UA Updated: 08/06/22 0746     URINE CULTURE --     COLONY COUNT: >100K cfu/ml Gram negative bacilli Ciprofloxacin and/or Levofloxacin falls within CLSI nonsusceptibility range due to outdated breakpoints. MIC without interpretation is for research use only. Interpretations, if provided may be invalid.      URINE CULTURE Pseudomonas aeruginosa     URINE CULTURE Pseudomonas aeruginosa   Sputum Culture  Collected: 08/02/22 0618   Order Status: Completed Specimen: Respiratory from Expectorated Updated: 08/04/22 0647     RESPIRATORY CULTURE --     Normal flora Normal flora       GRAM STAIN SMEAR --     EXPECTORATED SPUTUM >25 WBC's, <10 squamous epithelial cells; Lower respiratory secretions with little upper respiratory tract contamination. Few Gram positive cocci in pairs and clusters.     Blood Culture (x2 sets)  Collected: 07/29/22 0119   Order Status: Completed Specimen: Blood from Vein Updated: 08/03/22 0401     BLOOD CULTURE --     No growth @ 24 hours. No growth @ 48 hours. No growth @ 72 hours. No growth @ 96 hours. No growth @ 120 hours.     Narrative:     Collection has been rescheduled at 07/29/2022 00:54 Reason: miss  x2    Blood Culture (x2 sets) [159271819] Collected: 07/29/22 0119   Order Status: Completed Specimen: Blood from Vein Updated: 08/03/22 0401     BLOOD CULTURE --     No growth @ 24 hours. No growth @ 48 hours. No growth @ 72 hours. No growth @ 96 hours. No growth @ 120 hours.     Narrative:     Collection has been rescheduled at 07/29/2022 00:54 Reason: miss  x2    SARS-CoV-2, QL, PCR (STAT)   (Abnormal) Collected: 07/27/22 1317   Order Status: Completed Specimen: Nasopharyngeal from Nasophayngeal Updated: 07/27/22 1405     SARS-CoV-2 RNA Detected      Comment:   Reference value:  Undetected   Testing was performed using the Dx System.   Fact sheets for this Emergency Use Authorization (EUA) assay can be found at the following links:      For Healthcare Providers:     For Patients:    Test Performed by: Medical Center, D.O.      Narrative:     Symptomatic?->Yes Indications (select all that apply)->Admission Called to and read back, at 14:04 on 07/27/2022,