Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Chronic left ventricular failure, Chronic obstructive pulmonary disease, Condition aggravated, Coronary artery disease, Diabetic nephropathy
Clinical narrative: Date of Admission: 9/24/2023   Date of Discharge: 9/28/2023   Issues to be Addressed at Follow-up: COVID-19 infection-follow-up Cardiology follow-up-has not seen cardiology since 2019, worsening EF COPD clinic follow-up CHF clinic follow-up Admission Weight: Weight: 65.8 kg (145 lb 1 oz) (09/24/23 1619)  Baseline Creatinine: 1.6-1.8   Discharge Weight: Weight: 65.8 kg (145 lb) (09/25/23 1050) Discharge Creatinine:   Lab Results Component Value Date   Creatinine 1.88 (H) 09/28/2023       Estimated Target Weight (if known): unknown   Discharge Oxygen Saturation:     9/28/2023 O2 Sat % 92 O2 (LPM) -    Last EF:   LV EJECTION FRACTION Date Value Ref Range Status 09/25/2023 23 % Final    LEFT VENTRICULAR EJECTION FRACTION Date Value Ref Range Status 07/19/2019 55 % Final    Volume Status/Diuretic Plan until follow-up: Patient needs additional diuresis. Patient is being discharged placed on oral diuretics, patient has been tolerating oral diuretics prior to discharge this has been prescribed for 2 weeks with a follow-up with primary care physician.  Along with placement of eConsult for cardiology and CHF clinic.   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/25/2023  4:23 PM BLOOD CULTURE 2 Preliminary BLOOD   9/25/2023  4:22 PM BLOOD CULTURE Preliminary BLOOD   9/24/2023 12:10 PM BLOOD CULTURE 2 Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION       With multiple organ failure including respiratory failure, worsening CHF, and abnormal LFT   ? ASTHMA COPD OVERLAP SYNDROME (ASTHMA W COPD)   ? COVID-19 DISEASE   ? CAD (CORONARY ARTERY DISEASE) WO ANGINA   ? HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY       Echo 12/18/18:  Upper limits of normal left ventricle cavity size.  Systolic function is severely decreased with an ejection fraction of 30%.  Aortic sclerosis marked with at least mild stenosis (peak velocity of 2.1 m/sec and mean gradient of 10 mmHg). The velocity and mean gradient could  be underestimated due to poor LV systolic function.   ? ACUTE PULMONARY EDEMA       Cardiogenic   ? ELEVATED TROPONIN I   ? DM 2 W CKD STAGE 3A (GFR 45-59) W HTN   ? MEMORY LOSS       5/2021: Moca 15/30 - stopped taking Aricept because it made her feel "sick to stomach"   ? ACUTE EXACERBATION OF COPD       PFT data: DATE_______FVC(%)____________FEV1(%)__________ratio________meds     3/1/2016          1.64(64)                       0.66(34)                       0.41                 Dulera 200-5 2 puffs BID   Post                 1.81(71)                       0.81(41)                     0.45                  (<200mL improvement, no significant change) 8/18/2011        1.85(66)                       0.73(35)                       0.40 Post                 2.06(73)                       0.85(40)                       0.41     Resolved Hospital Problems   Diagnosis Date Resolved ? ACUTE HYPOXEMIC RESPIRATORY FAILURE 09/28/2023 ? BACTEREMIA 09/28/2023     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Severe sepsis with acute organ dysfunction Acute hypoxic respiratory failure-resolved Possible acute infective exacerbation of COPD Possible superimposed bacterial pneumonia with COVID-19 infection Staphylococcus epidermidis bacteremia-likely contamination This 80-year-old lady who presents emergency department with significant difficulty breathing, requiring oxygen at the time of initial evaluation was underlying COPD, has been having progressive worsening cough with sputum production, radiological evaluation showed evidence of pneumonia, provided with empiric antibiotics subsequently de-escalated to Rocephin and doxycycline.  Received total of 4 days of antibiotics subsequently transition to oral antibiotics cefdinir and doxycycline for further 3-day duration.   Patient has been remained on room air for at least 24 hours prior to discharge, remained in COVID isolation during this hospital course and recommended to remain on isolation till 10/4/2023.  Patient received 3 doses of remdesivir and 1 dose of dexamethasone, has not deemed appropriate to continue this regimen as patient's clinical improvement has been noted with oral antibiotics in the absence of any need for significant bronchospasm steroids been discontinued.   Blood cultures 1 of 4 bottles noted to have Staph epidermidis, deemed likely contamination.  Repeat cultures remain negative.   Acute pulmonary edema Likely chronic systolic and diastolic grade 1 congestive heart failure Demand myocardial ischemia Patient has known history of systolic congestive heart failure with ejection fraction 30 to 35%, previously seen cardiologist in 2019 Dr., patient has not followed up since then.  Education has been provided on fluid restriction and salt restriction, appropriate and adequate diuresis has been achieved.  Patient has been provided with Lasix of 40 mg daily along with spironolactone 12.5 mg daily for further 14 days with outpatient close follow-up with primary care physician, CHF clinic and cardiology team.  I have advised on restriction of the salt as well as fluids to 1500 mils per day, patient has been able to ambulate with help of walker during hospital stay and has not required any home health or physical therapy needs at the time of discharge.   Type 2 diabetes mellitus Patient has required Lantus of 10 units during this hospital course along with Humalog correction scale, once the steroids were discontinued blood sugars remained well controlled.  Patient has been continued on oral hypoglycemic agents within the discharge.   Coronary artery disease History of CVA without any significant residual deficit Patient has been continued on Plavix along with high-dose statin, no change in the antiplatelet therapy echo during this hospital course.  Patient expresses that she has been intolerant of aspirin in the past.   CKD stage III Patient's renal functions remained stable at the time of discharge, baseline creatinine fluctuates between 1.6-1.8, recommend to continue with Lasix and spironolactone at the time of discharge with advised to follow-up with primary care physician with repeat lab data in 1 week.   History of memory loss Patient currently noncompliant with Aricept as it causes to have side effects of nausea.   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Acute hypoxic respiratory failure Severe sepsis with acute organ dysfunction Possible superimposed bacterial pneumonia with COVID-19 infection.   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: Full Code       Note Details  Author (M.D.) File Time 9/28/2023 12:59 PM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/24/2023  ED to Hosp-Admission (Discharged) on 9/24/2023  ED to Hosp-Admission (Discharged) on 9/24/2023   Detailed Report  Note viewed by patient Hospital Problem List   DM 2 W CKD STAGE 3A (GFR 45-59) W HTN  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION  ACUTE EXACERBATION OF COPD  MEMORY LOSS  ACUTE PULMONARY EDEMA  COVID-19 DISEASE  ELEVATED TROPONIN I  BACTEREMIA Resolved  ASTHMA COPD OVERLAP SYNDROME (ASTHMA W COPD)  ACUTE HYPOXEMIC RESPIRATORY FAILURE Resolved  HEART FAILURE W REDUCED LVEF <=30%, UNSPECIFIED ACUITY  CAD (CORONARY ARTERY DISEASE) WO ANGINA Care Timeline  09/24   Admitted from ED 1556 09/28   Discharged 1259  Discharge   Home or Self Care.    Discharge Instructions (AVS) (Printed 9/28/2023)