Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Oesophagogastroduodenoscopy abnormal, Pathology test, Rectal haemorrhage, SARS-CoV-2 test positive
Clinical narrative: Date of Admission: 10/29/2023   Date of Discharge: 10/31/2023   Issues to be Addressed at Follow-up: -restarting Pradaxa (on 11/3/23)   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/27/2023  2:02 PM SURGICAL PATHOLOGY In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) GI HEMORRHAGE   ? HYPERLIPIDEMIA   ? HX OF EMBOLIC STROKE W UNSPECIFIED RESIDUAL DEFICITS   ? OBSTRUCTIVE SLEEP APNEA       Moderate OSA (AHI=16.1), severe in supine posture (AHI=60.3) with severe O2 desaturation; on cpap     ? MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION   ? HTN (HYPERTENSION)   ? HX OF ATRIAL FIBRILLATION       He had an ablation on 11/1/13      Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 72 YO M w/ h/o HTN, HLD, OSA on CPAP, L-LE bypass, Afib s/p ablation on Pradaxa, embolic CVA, depression.    10/27 - Outpatient EGD/colonoscopy with 3 polyps removed.    Presented 10/29 with rectal bleeding shortly after restarting Pradaxa.     Patient was prepped for colonoscopy and bleeding ceased during prep. H/H remained stable and coloscopy was cancelled. Diet advanced without return of any signs of bleeding. Patient will restart Pradaxa on 11/3/23 to reduce risk of re-bleed.    Of note, patient also tested positive on home COVID-19 test with symptoms beginning on 10/27. No hypoxemia or fevers during inpatient stay. Will continue previously prescribed lagevrio on discharge.    O: BP 102/72  | Pulse 64  | Temp 97.1 °F (36.2 °C)  | Resp 18  | Ht 5' 10"  | Wt 87.9 kg (193 lb 12.6 oz)  | SpO2 97%  | BMI 27.81 kg/m²   GEN: laying comfortably, NAD. AOx3. CHEST: CTABL HEART: RRR ABD: soft, NT, ND, BS+ EXT: no LE edema   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Post-polypectomy GI Bleeding   Complications: none   Consults:  GASTROENTEROLOGY - INITIAL INPATIENT CONSULTATION. GASTROENTEROLOGY - ONGOING INPATIENT CONSULTATION. HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author  (M.D.) File Time 10/31/2023 12:12 PM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #   Admit Date 10/29/2023  ED to Hosp-Admission (Discharged) on 10/29/2023  ED to Hosp-Admission (Discharged) on 10/29/2023   Detailed Report  Note viewed by patient Additional Orders and Documentation   Results    Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HTN (HYPERTENSION)  MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION  GI HEMORRHAGE  HX OF ATRIAL FIBRILLATION  HYPERLIPIDEMIA  OBSTRUCTIVE SLEEP APNEA  HX OF EMBOLIC STROKE W UNSPECIFIED RESIDUAL DEFICITS Care Timeline  10/29   Admitted from ED (Observation) 2234 10/31   Discharged 1130  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/31/2023) Medication List at Discharge   cyanocobalamin (vitamin B-12) 1,000 mcg Oral DAILY  dabigatran etexilate mesylate 150 mg Oral 2 TIMES A DAY, Please restart taking on MORNING OF 11/3/23.  dorzolamide HCl 2 % 1 Drop Right eye 2 TIMES A DAY  fluticasone propionate 50 mcg/actuation 2 Sprays Each nostril DAILY  ipratropium bromide 21 mcg (0.03 %) 2 Sprays Each nostril 2 TIMES A DAY  latanoprost 0.005 % 1 Drop Right eye EVERY EVENING  lisinopril 5 mg Oral DAILY  molnupiravir 800 mg Oral EVERY 12 HOURS  pantoprazole sodium 40 mg Oral DAILY BEFORE BREAKFAST  ranolazine 500 mg Oral 2 TIMES A DAY, start after stopping sotalol, to suppress PVCs.  rosuvastatin calcium 5 mg Oral DAILY, to prevent heart attacks and strokes  sertraline HCl 50 mg Take 1 tablet by mouth daily. Note change in dosage.  tamsulosin HCl 0.4 mg Oral DAILY, . Take 30 minutes after dinner or before bed