Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abnormal, Condition aggravated, Coronary artery disease, Cough, Dyspnoea
Clinical narrative: Date of Admission: 10/26/2023   Date of Discharge: 10/27/2023     Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 9/27/2023 to 10/28/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA       9/15/2022 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Calcifications seen on CT Scan. No chest pain or shortness of breath. No history of cath.  Discussed risks / benefits of statin and she is agreeable.  No aspirin for primary prevention of heart attack or stroke given age.    ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION       4/13/2023  - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Stable. History of severe depression, no longer on medications.    9/15/2022: Reports doing much better since no longer in isolation due to pandemic. No medications.    10/21/2020: History of Melancholic and psychotic features. Symptoms not consistent with bipolar disorder.    ? HTN (HYPERTENSION)       8/30/2023  Just purchased blood pressure cuff. Verified with physical therapist at home that it is similar.  Stopped losartan 5 days ago because read it can cause respiratory infections.    Today, blood pressure was 118/70.    A/P: off blood pressure medication. She will monitor and follow up if home blood pressure is going higher than 135/85.      5/31/2023: Losartan 100mg  Started losartan early 2023.  Had to slowly increase losartan as blood pressure was getting higher. Now blood pressure on the lower side. Monitor for lightheadedness / dizziness.      Vitals Flowsheet Link     BP Readings from Last 3 Encounters: 05/31/23 107/66 05/25/23 139/79 05/03/23 155/78    Pulse Readings from Last 1 Encounters: 05/31/23 69    Lab Results Component Value Date   CR 0.68 05/03/2023   GFRESTIM >60 05/03/2023   GFRESTIM >60 07/13/2022   K 4.5 05/03/2023   NA 144 07/13/2022   MALBCREAT 36.1 (H) 07/13/2022       ? COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)       7/20/2023  Requesting to change to Vacaville location (since she moved to this area).  Currently being treated for aspergillosis and does not feel that symptoms are improving.  Would like second opinion.  Referred to COPD care management team as well to review her medications.     4/12/2023 DOV Recent upper respiratory infection / COPD exacerbation. Given antibiotic about 3 weeks ago. Symptoms overall improved but still having some shortness of breath. Has 3 boxes of combivent and wants to use those before restarting spiriva.  Not taking Spiriva.    O: gen - alert, no acute distress.  Good air movement, no wheezes or rhonchi.    A/P: continue Wixela. Complete combivent prescription then change back to Spiriva (+ albuterol as needed).  Follow up if shortness of breath does not continue to improve after recent upper respiratory infection.    9/15/2022 DOV Taking comibent 3-4 times per day. Sometime has to take a deep breath after doing activities. Can walk 1.5 mile and feels better when she does that. Not taking Wixela because does not notice any immediately benefits when she takes it. Former smoker (30+ pack years, quit in 2011)   O: calm, alert, no acute distress.    A/P: lengthy discussion today about prevention medications.  Will change as follows: restart Wixela and add Spiriva (had some constipation with it 10 years ago but willing to retry).  Albuterol only as needed.  Update on symptoms in 1 month.    pft 4/9/12 Dr. Spirometry: Severe Obstruction  Lung volumes: Normal lung volumes Bronchodilator response: No change post bronchodilator.  The lack of a bronchodilator response in the laboratory does not preclude a clinical response to bronchodilator therapy.  Diffusion: Moderate decrease in DLCO which does not correct       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: 77-year-old woman history of multiple medical problems, patient recently hospitalized from 9/22 through 9/30 for pneumonia, patient has history of COPD, CAD, hypertension, invasive aspergillus pulmonary infection, during her last hospitalization patient was seen by infectious disease and was discharged on antifungal and abx therapy which she has completed.  She presents with mild shortness of breath for the past 2 days requiring oxygen, dry cough, no fevers.  Patient is found to be COVID-19 positive, symptoms are overall mild, denies myalgias, patient reports that she is feeling better.  Patient reports her symptoms are not consistent with how she felt when she had pneumonia.  Patient reports mild fatigue.   Patient admitted for observation, was treated with remdesivir and steroids, patient feels better and wants to go home. Patient is no longer requiring O2 and is stable for d/c home today, do not think patient requires discharge on oral decadron for covid as she is no longer requiring O2 and does not appear to have acute respiratory failure, given history of recurrent pulmonary infections, risk/benefits likely favor no further steroids.    Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Covid-19   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR       Note Details  Author (M.D.) File Time 10/27/2023  9:48 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 10/26/2023  ED to Hosp-Admission (Discharged) on 10/26/2023  ED to Hosp-Admission (Discharged) on 10/26/2023   Detailed Report  Note shared with patient Hospital Problem List   COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)  HTN (HYPERTENSION)  MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION  CAD (CORONARY ARTERY DISEASE) WO ANGINA  COVID-19 DISEASE Care Timeline  10/26   Admitted from ED (Observation) 1825 10/27   Discharged 1058  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/27/2023)