Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Fall, Gait inability, Gastrooesophageal reflux disease, Glaucoma, Hypertension
Clinical narrative: Date of Admission: 9/12/2023   Date of Discharge: 9/13/2023   Issues to be Addressed at Follow-up: Blood cultures will need follow-up Patient was discharged on empiric antibiotics for 7 days total   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/12/2023  4:18 AM BLOOD CULTURE 2 Preliminary BLOOD   9/12/2023  3:40 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? HYPOXIA   ? WEAKNESS   ? HTN (HYPERTENSION)   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? SEVERE OBESITY EQUIVALENT (BMI 35-39.9 W CO-MORBIDITY)   ? DM 2 W GLAUCOMA   ? BILAT PRIMARY OPEN ANGLE GLAUCOMA, MODERATE STAGE     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: Patient is a pleasant 79-year-old gentleman with past medical history consisting of morbid obesity, hypertension type 2 diabetes with glaucoma gastric, gastroesophageal reflux disease Perrone's disease, Hailey-Hailey disease abnormal chest x-ray with nodule which has been followed over 2 years and have stayed the same.  Bilateral pseudophakia, left hearing loss and actinic keratosis. Patient was brought to emergency room by family after patient sustained a fall and over the past couple of days has been confused to awake alert oriented x2 per daughter and wife.  Patient's family states patient was at home at his baseline ADLs without any assistive devices but for the past 2 3 days he is progressively gotten weaker and passed 1 day he was unable to get out of bed.  They said he has progressively become weak was not able to walk and slowly at one point slid out from the bed to the ground without any loss of consciousness or head trauma.  Wife states patient has been progressively confused which is different from his baseline when he is quite attentive with independent ADLs.  Patient and family endorses having chills at home and low-grade fever productive cough and episodes of vomiting nonbloody. Patient denied any chest pain headache diarrhea neck stiffness upper or lower extremity numbness or weakness which was focal no swallowing difficulties chest back or abdominal pain dark or bloody stool or burning in the urine.  Patient wife was present at bedside also states she was tested positive for COVID but her symptoms has not been bad chest sore throat and very mild myalgias.  Both wife and patient has been vaccinated, per the patient this is the second episode of COVID last one was March 2023.   Patient had remarkable improvement after IV fluid hydration antibiotics were started.  Including improvement in his blood work.  Sodium normalized.  Patient was ambulating without evidence of hypoxia and was on room air.   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: Full Code     Note Details  Author (M.D.) File Time 9/13/2023  3:11 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/12/2023  ED to Hosp-Admission (Discharged) on 9/12/2023  ED to Hosp-Admission (Discharged) on 9/12/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   GERD (GASTROESOPHAGEAL REFLUX DISEASE)  HTN (HYPERTENSION)  BILAT PRIMARY OPEN ANGLE GLAUCOMA, MODERATE STAGE  DM 2 W GLAUCOMA  SEVERE OBESITY EQUIVALENT (BMI 35-39.9 W CO-MORBIDITY)  COVID-19 PNEUMONIA  HYPOXIA  WEAKNESS Care Timeline  09/12   Admitted from ED (Observation) 1221 09/13   Discharged 2023  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 9/13/2023) Medication List at Discharge   atorvastatin calcium 40 mg Oral DAILY  carbamide peroxide 6.5 % Instill 5 to 10 drops into affected ear(s) 2 times a day for up to 4 days as needed for excessive earwax or as directed by your doctor. Follow package directions for proper use  clindamycin phosphate 1 % Topical 2 TIMES A DAY  doxycycline monohydrate 100 mg Oral 2 TIMES A DAY  latanoprost 0.005 % 1 Drop Both eyes EVERY BEDTIME, for Glaucoma  losartan potassium 50 mg Oral 2 TIMES A DAY  metformin HCl 500 mg Take 1 tablet by mouth every morning AND 2 tablets every evening with a meal.  prednisolone acetate 1 % Instill 1 drop in operated eye 4 times a day for 1 week, then 3 times a day for 1 week, then 2 times a day for 1 week, then daily for 1 week, then stop  sildenafil citrate 20 mg Take 3 tablets by mouth as needed (one hour prior to sexual activity) . Do not exceed 1 dose (3 tablets) in 24 hours  tacrolimus 0.1 % Apply to affected area(s) 2 times a day . May cause stinging sensation when first applied - this will improve over time. May refrigerate to prevent this. Stop when rash has resolved  triamcinolone acetonide 0.1 % Mix 1:1 with clotrimazole cream and apply topically twice a day. Stop when rash is gone. Do not use on face, neck, or skin folds unless directed by physician