Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Hypertension, Hypoglycaemia, Hyponatraemia, Incontinence, Ischaemic cardiomyopathy
Clinical narrative: (P.A.-C)  PHYSICIAN ASSISTANT (P.A.) Specialty:  GENERAL, OTHER Discharge Summary    Attested  Attested       Attestation signed by (M.D.) at 12/9/2023  1:45 PM   I have reviewed and verified the content of this Discharge Summary. The Discharge Summary accurately reflects the outcome of the patient?s hospitalization and/or treatment, the disposition of the patient, and the patient?s final diagnosis. I have verified that the Discharge Summary also provides for appropriate follow-up care to facilitate proper continuity of care.    EMERGENCY GENERAL SURGERY DISCHARGE SUMMARY    Note initiated:  PA-C   12/9/2023 9:47 AM Date of Admission: 12/6/2023   Date of Discharge: 12/9/2023   Issues to be Addressed at Follow-up: COVID sx - PCP f/u  Thrombocytopenia, ?resuming ASA 81 - PCP f/u Abx completion Wound healing   Pending Study Results at Discharge: Pathology   Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE CHOLECYSTITIS   ? COVID-19 DISEASE   ? DM 2 W HYPERLIPIDEMIA   ? CAD WO ANGINA, W HX OF MI   ? ISCHEMIC CARDIOMYOPATHY       EF 40-45%   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? HX OF DIVERTICULITIS       s/p  colon resection for ruptured diverticultis  10 years ago in hospital .    ? FATTY LIVER   ? DM 2   ? OBESITY, BMI 30-34.9, ADULT   ? CAD WO ANGINA, PRESENCE OF STENT   ? INTERMITTENT ASTHMA, CONTROLLED   ? PRESENCE OF STENT, CORONARY ARTERY       3 stents  in hospital , 12/10/09.  taxus x1  11/10/09 and promus x 2 12/10/09   ? HYPERLIPIDEMIA   ? HTN (HYPERTENSION)     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Future Appointments:  Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Dec 19, 2023  9:15 AM Telephone Visit (P.A.-C) SURGERY        Medications, instructions, follow up information:   Current Facility-Administered Medications Medication Dose Route ? AUGMENTIN 875-125 mg 1 tablet (Amoxicillin-Pot Clavulanate)  1 tablet Oral ? DUONEB 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Soln 3 mL (Ipratropium-Albuterol)  3 mL NEBULIZATION -UNSPEC ? oxyCODONE IR Tab 5 mg (ROXICODONE)  5 mg Oral ? oxyCODONE IR Tab 10 mg (DAZIDOX)  10 mg Oral ? Pharmacy Renal Monitoring  1 Each Miscell. (Med.Supl.;Non-Drugs) ? Chlorhexidine Gluconate Oral Soln 15 mL (PERIDEX)  15 mL Oral ? Docusate Sodium Cap 250 mg (COLACE)  250 mg Oral ? Sennosides Tab 17.2 mg (SENOKOT)  17.2 mg Oral ? Bisacodyl Supp 10 mg (DULCOLAX)  10 mg Rectal ? WEB LINK HYPOGLYCEMIA  1 Each Miscell. (Med.Supl.;Non-Drugs) ? D50W Inj Syg 12.5 g  25 mL intraVENOUS ? D50W Inj Syg 25 g  50 mL intraVENOUS ? Glucagon Inj 1 mg  1 mg intraMUSCULAR ? D5W IV Premix  100 mL/hr intraVENOUS ? Acetaminophen IV Soln 1,000 mg (OFIRMEV)  1,000 mg intraVENOUS ? Pantoprazole Inj 40 mg (PROTONIX)  40 mg intraVENOUS ? Ondansetron (PF) Inj 4 mg (ZOFRAN)  4 mg intraVENOUS ? Metoclopramide Inj 10 mg (REGLAN)  10 mg intraVENOUS ? Melatonin Tab 3 mg (MELATIN)  3 mg Oral   Or ? Melatonin Tab 3 mg (MELATIN)  3 mg Nasogastric ? traZODone Tab 50 mg (DESYREL)  50 mg Oral   Or ? traZODone Tab 50 mg (DESYREL)  50 mg Nasogastric ? diphenhydrAMINE Cap 25 mg (BENADRYL)  25 mg Oral   Or ? diphenhydrAMINE Inj 25 mg (BENADRYL)  25 mg intraVENOUS ? Flu Vaccine QS 2023-24 (65 yrs up) PF IM Syg 0.7 mL (FLUZONE HIGHDOSE QUAD)  1 Each intraMUSCULAR ? Insulin Regular Human Sliding Scale Inj (HumuLIN R/NovoLIN R)   Subcutaneous ? Atorvastatin Tab 80 mg (LIPITOR)  80 mg Oral ? Carvedilol Tab 3.125 mg (COREG)  3.125 mg Oral ? Losartan Tab 25 mg (COZAAR)  25 mg Oral ? [Manual Hold] Fluticasone 50 mcg/actuation Nasal Inhaler 1 Spray (FLONASE ALLERGY RELIEF)  1 Spray Each nostril ? Sodium Chloride 0.9% IV Premix  125 mL/hr intraVENOUS ? PHARMACY MONITORING ANTIBIOTIC STEWARDSHIP  1 Each Miscell. (Med.Supl.;Non-Drugs) ? Aspirin Chew Tablet 81 mg  81 mg Oral ? Pharmacy Monitoring  1 Each Miscell. (Med.Supl.;Non-Drugs) ? Metoclopramide Inj 5 mg (REGLAN)  5 mg intraVENOUS ? BUPivacaine-Epineph PF 0.5 %-1:200,000 Inj (PYXIS OVERRIDE)     ? Iohexol 240 mg iodine/mL Inj (PYXIS OVERRIDE)         Hospital Course and Significant Findings: Patient is a 76 Y old male w/ PMH of BMI 29, HTN, CAD (PCI x 3 in 2009), DM2 sigmoid colectomy for diverticulitis ~2005 presenting to ED 12/6/23 with abdominal pain x 4 days. Pain mostly right upper quadrant. Also had incontinence, dizziness, and difficulty with gait intermittently. In ER found to have WBC 23, hyponatremia, mildly elevated LFT's. CT head negative. CT A/P with 1.3cm pancreatic cyst in uncinate process, 3mm non-obstructive renal calculus and evidence of cholecystitis. U/S RUQ with sludge/debris, thickened gallbladder wall up to 8mm, CBD 4mm. Pt underwent lap chole 12/7 and found to have gangrenous gallbladder with necrotic GB wall. Pt admitted for additional IV abx - zosyn.   HBS consulted to assist with management of MMP as well as work up for dizziness / incoordination. MRI head ordered to r/o stroke, which revealed no acute findings. TTE showed reduced EF of 40-45% w/ regional wall motion abnormalities, which are similar to TTE from 2014.    Patient noted to have thrombocytopenia. Discussed with HBS and ok to continue to hold until f/u PCP appt.   On POD#2 he is tolerating a regular diet and having BM. He is minimally symptomatic with respect to is COVID infection so albuterol inhaler ordered for discharge. He is stable for discharge home with surgery f/u arranged. Return precautions discussed and patient is agreeable with the plan    Physical exam  General - resting comfortably, NAD Chest - CTAB, no wheezes Heart - RRR Abdomen - soft, NT/ND, no rebound or guarding Surgical incisions - glue in place, no erythema or discharge   Primary Procedures at Hospital:  Procedure(s): CHOLECYSTECTOMY LAPAROSCOPIC CHOLANGIOGRAM   Operations / Procedures: 12/7 - lap chole, IOC   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  See Discharge Diagnoses   Complications: none   Consults:  HBS / INTERNAL MEDICINE   Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code   The case and plan of the day was discussed with Dr., MD. PA-C   12/9/2023 9:48 AM      Cosigned by: (M.D.) at 12/9/2023  1:45 PM  Note Details  Author (P.A.-C) File Time 12/9/2023  1:45 PM Author Type PHYSICIAN ASSISTANT (P.A.) Status Signed Last Editor (P.A.-C) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 12/6/2023  ED to Hosp-Admission (Discharged) on 12/6/2023  ED to Hosp-Admission (Discharged) on 12/6/2023   Revision History   Detailed Report  Note shared with patient Linked Episodes  CHOLECYSTECTOMY LAPAROSC From 12/7/2023 to 12/8/2023  Hospital Problem List   HYPERLIPIDEMIA  HTN (HYPERTENSION)  INTERMITTENT ASTHMA, CONTROLLED  CAD WO ANGINA, PRESENCE OF STENT  DM 2  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  ISCHEMIC CARDIOMYOPATHY  CAD WO ANGINA, W HX OF MI  DM 2 W HYPERLIPIDEMIA  ACUTE CHOLECYSTITIS  PRESENCE OF STENT, CORONARY ARTERY  OBESITY, BMI 30-34.9, ADULT  FATTY LIVER  HX OF DIVERTICULITIS  COVID-19 DISEASE Care Timeline  12/07   Admitted from ED (Observation) 1213    CHOLECYSTECTOMY LAPAROSCOPIC    Admitted 1719 12/09   Discharged 1307  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/9/2023)