Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Blood lactate dehydrogenase increased, Blood osmolarity increased, Blood pH decreased, Blood potassium increased, Blood sodium normal
Clinical narrative: Date of Service Nov-01-2022 1314  Date of Admission Admit Date: Oct-27-2022  Date of Discharge Date of discharge Nov-01-2022  Allergies No Known Allergies  Chief Complaint difficulty breathing  Final Diagnoses COVID-19  Bacteremia  Procedure(s) Performed None  Lab Results Nov-01-2022 0437 Hematology WBC  6.0RBC  2.02HGB  7.7HCT  24.3MCV  120.3MCH  38.1MCHC  31.7RDW  14.0RDWSD  61.4PLT  200MPV  11.8AUTONEU%  76.2AUTOLYM%  9.3AUTOMON%  6.8AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  4.6AUTOLYM#  0.6AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.0SCAN DIF  YBAND %  6SEG %  78LYMPH %  8MONO %  6META %  2NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.45IG%  7.5 Nov-01-2022 0437 Chemistry GLUCOSE  146BUN  54CREAT  1.3MDRD GFR  53NA  140K  5.4CL  104CALCIUM  9.1ALK PHOS  59CO2  29.8AST  115ALT  164AST/ALT  0.7TL PROT  6.6ALBUMIN  2.6TBILI  0.3DBILI  0.2OSMO  296.8ANION GP  11.6BUN/CRE  41.5CRP  1.30 Oct-29-2022 0640 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Oct-29-2022 0630 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Oct-29-2022 0524 Chemistry HGBA1C  6.1 Oct-29-2022 0524 Serology PROCALC  0.21 Oct-28-2022 1223 Chemistry GLUCOSE  135BUN  73CREAT  2.6MDRD GFR  24NA  145K  5.7CL  109CALCIUM  8.9CO2  27.9OSMO  312.3ANION GP  13.8BUN/CRE  28.1VIT B12  1894FERRITIN  526FOL  >20.0IRON  60TIBC  250% SAT  24 Oct-28-2022 1223 Blood Gas PH VEN  7.210PCO2 VEN  72.8PO2 VEN  40.0BICARB V  27.7BE VEN  -0.1CO2 CT V  27.9O2 SAT V  61.4 Oct-28-2022 0500 Chemistry TROPI-HS  78LDH  397 Oct-28-2022 0024 Urinalysis Department SPECGRAV  >=1.030U-PH  5.5LEUCOCYT  NegativeNITRITES  NegativePROTEIN  TraceGLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  NegativeCOLOR  YellowCLARITY  ClearMICROSCP  NCULTURE  N Oct-28-2022 0001 Chemistry TROPI-HS  84 Oct-27-2022 2352 Blood Gas PH  7.17PC02  77.2PO2 ART  83BICARB  26.7BE  -1.9CO2 CT  26.9O2 SAT  94.2O2 THER  50TYPEABG  Arterial Oct-27-2022 2226 Blood Gas PH VEN  7.14PCO2 VEN  82.8PO2 VEN  50BICARB V  27.1BE VEN  -2.0CO2 CT V  27.6O2 SAT V  71.7 Oct-27-2022 1959 Chemistry CRP  7.6TROPI-HS  90 Oct-27-2022 1933 Microbiology C BLD  Streptococcus salivariusC BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Oct-27-2022 1836 Blood Gas PH VEN  7.180PCO2 VEN  81.6PO2 VEN  46.0BICARB V  29.6BE VEN  0.9CO2 CT V  29.7O2 SAT V  65.3 Oct-27-2022 1826 Serology COVID  PosINFLUA  NegINFLUB  NegPROCALC  0.29CVD1TEST  NCVDEMPHC  NCVDSYMP  NCVDSYMDT  UCVDHOSP  NCVDICU  NCVDRESID  NCVDPREG  N Oct-27-2022 1826 Hematology WBC  15.3RBC  2.19HGB  8.3HCT  26.8MCV  122.4MCH  37.9MCHC  31.0RDW  15.2RDWSD  67.8PLT  225MPV  10.8AUTONEU%  68.1AUTOLYM%  10.9AUTOMON%  6.3AUTOEOS%  0.1AUTOBAS%  0.5AUTONEU#  10.4AUTOLYM#  1.7AUTOMON#  1.0AUTOBAS#  0.1AUTOEOS#  0.0NRBC%  0.1NRBC  0.0HGB/HCT  3.2IG#  2.15IG%  14.1 Oct-27-2022 1826 Chemistry GLUCOSE  153BUN  63CREAT  2.6MDRD GFR  24NA  141K  6.0CL  107CALCIUM  8.7ALK PHOS  80CO2  28.6AST  83ALT  56AST/ALT  1.5TL PROT  7.6ALBUMIN  3.1TBILI  0.4OSMO  302.3ANION GP  11.4BUN/CRE  24.2LACTATE  0.70PROBNP  3253TROPI-HS  105 Imaging Results Medical Center  Transthoracic Echocardiogram Report Patient Name: Gender: Male   Study Date: 28-Oct-2022 Height(Cm): 185 Weight(Kg): 145.10 BSA: 2.73 Ref. Physician:  Quality: Good Procedures: Echocardiogram complete with 2D, M-Mode, and Doppler examination. Indications: Dyspnea. 2D/M Mode Doppler Measurement Value Normal Range Measurement Value Normal Range LVIDd (MM) 5.9 cm AV Area Vmax 2.0 cm2 LVIDs (MM) 4.1 cm AV Area VTI 2.1 cm2 IVSd (MM) 1.5 cm AV Peak PG 31.0 mmHg LVPWd (MM) 1.5 cm AV Mean PG 17.0 mmHg LA Dimen MM 5.2 cm MV E/A 0.9 LVOT Peak Vel 1.2 m/sec E/E` 14.1 Findings Left Ventricle: Normal left ventricular systolic function with LVEF >60%. Moderate left ventricular hypertrophy (measuring 1.4 - 1.7 cm). Impaired relaxation (Grade I diastolic dysfunction). Left Atrium: Moderate enlargement of the left atrium with LA index volumes between 42 48cm2. Mitral Valve: Mild mitral regurgitation. Aortic Valve: Mild aortic stenosis (AVA > 1.5 cm2). Mild aortic regurgitation. Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function. Right Atrium: Mild RA enlargement (40mm - 45mm). Atrial Septum: Normal atrial septum. Tricuspid Valve: Mild tricuspid regurgitation. The estimated Peak RVSP is 28 mmHg. Pulmonic Valve: Normal pulmonic valve appearance and function with trivial (physiologic) regurgitation. IVC: Normal inferior vena cava appearance and respiratory collapse. Aorta: Aortic root size is normal. Pericardium: Small pericardial effusion. No echocardiographic evidence to suggest pericardial tamponade. Conclusions Normal left ventricular systolic function with LVEF >60%. Moderate left ventricular hypertrophy (measuring 1.4 - 1.7 cm). Impaired relaxation (Grade I diastolic dysfunction). Moderate enlargement of the left atrium with LA index volumes between 42- 48cm2. Mild mitral regurgitation. Mild aortic stenosis (AVA > 1.5 cm2). Mild aortic regurgitation. Mild tricuspid regurgitation. The estimated Peak RVSP is 28 mmHg. Small pericardial effusion. No echocardiographic evidence to suggest pericardial tamponade. Electronically Signed By: D.O. 28-Oct-2022 09:07:01 -0500 Patient Name:   Study Date: 28-Oct-2022 ------------------------------  MEDICAL CENTER  IMAGING REPORT Patient Name: Date of Exam: 10/27/2022 Gender: M Ordering Physician: DO Exam Description: CH-CHEST 1V DR PATIENT NAME:  DATE OF BIRTH:   RAD NUMBER:   PHYSICIAN  DO DATE OF EXAM Oct 27, 2022 7:12:43 PM CDT PROCEDURES CR - Chest 1 view HISTORY Dyspnea IV CONTRAST (if appl) Single view of the chest. COMPARISON: None FINDINGS: Cardiomegaly. Atherosclerotic thoracic aorta. Airspace opacity within the mid to lower lungs. Bronchial wall thickening. No definite pleural effusion. No pneumothorax. No acute fracture. IMPRESSION: 1. Pulmonary opacities along the lung bases bilaterally suspicious for a multifocal infection. There is likely superimposed pulmonary edema. 2. Cardiomegaly. Correlate clinically for congestive heart failure. This exam was interpreted on workstation DIAGRAD-PC7 DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/28/2022 12:53 AM CDT ------------------------------------------------------------  Functional Status* Impaired mobility, Activity of daily living - Needs assistance  Mental Status* Normal Cognition  Social History tobacco use Current Every Day Smoker, 2 Packs Per Day, 63 yrs, Smoking Cessation Yes  alcohol use No Known Use  drug use No Known Use  marital status Married  general comment Patient lives alone.  Health Concerns Hyperkalemia  COVID-19  Bacteremia  Pneumonia  Current Every Day Smoker, 2 Packs Per Day, 63 yrs  Father Deceased Accident @ unknown age  Mother Deceased @ unknown age Essential hypertension; Dyslipidemia  Tobacco Cessation* Patient will receive tobacco cessation counseling at his/her post-hospital visit  Vital Signs Nov-01-2022 1600 T 98.6 HR 74 RR     21 BP   131 / 55 O2Sat 94 O2L 4 Nov-01-2022 0456 WGT 301.8 on 4 L via nasal cannula  PHYSICAL EXAM CONSTITUTIONAL: Patient appears comfortable and in no acute distress. ORAL:  CARDIOVASCULAR: Heart has regular rate and rhythm, pulses are 2/2 in the upper extremities, no edema noted. RESPIRATORY: Lung sounds diminished in the lower lobes. No wheezing. Respiratory effort is non-labored. Seen wearing NC.  GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended.  NEUROLOGICAL: Patient is alert and generally oriented. Sensation is grossly intact. PSYCHIATRIC: Patient's mood is euthymic, affect is appropriate. RASS of 0.  Hospital Course The patient is a 70-year-old male presented to the emergency room 10/27/2022 with complaints of shortness of breath for week. The patient is evaluated and then admitted to the Medical inpatient service for sepsis and acute on chronic respiratory failure. The patient's other acute diagnoses included acute exacerbation of COPD, COVID with possible secondary bacterial, AKI on CKD, hyperkalemia, and elevated troponins on admission. Patient's troponins and renal function improved with fluids as his sepsis resolved, likely secondary to poor perfusion. His COVID was treated with steroids, Remdesivir, and Actemra. He was given ceftriaxone and azithromycin for his superimposed bacterial pneumonia and possible bacteremia. 2/4 bottles of the sample lab draw grew S. salivarius which is likely contaminant. Repeat blood cultures were negative. However, given patient's presentation and sickness, and through shared decision making, it was decided to complete the 14 day course of treatment for bacteremia and will discharge him on cefdinir 300mg BID for 9 days. Patient's hyperkalemia was treated with kayexelate, Lasix, and insulin with dextrose. His COPD exacerbation was treated with BIPAP, breathing treatments, steroids, and antibiotics as described above under pneumonia. Patient will be discharged on a steroid taper, see discharge medications.    During his stay, patient developed delirium. He got up when he was weak, tried to pull his lines, and was agitated. Given his illness and weakness, his delirium was controlled with precedex titration in addition to reorienting patient to surroundings and self. It was likely secondary to his hospital stay, being confined to the hospital room, and having lines. His agitation improved as lines were discontinued. On the day of discharge, patient was not confused nor agitated. We anticipate that with return to his home environment, his behaviors will resolve and do not feel he requires medication on discharge. This was discussed with the patient and family and they also agreed and did not want to try Seroquel on discharge.  Condition at Discharge Stable  Discharge Medications Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 PUF INHALATION EVERY 4 HOURS AS NEEDED for SHORTNESS OF BREATH Allopurinol Oral Tablet 100 MG 100 MG ORALLY ONCE A DAY Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML 1 VL NEBULIZED INHALATION TWICE DAILY Budesonide Inhalation Suspension 0.5 MG/2ML 1 VL NEBULIZED INHALATION TWICE DAILY Carvedilol Phosphate ER Oral Capsule Extended Release 24 Hour 20 MG 20 MG ORALLY ONCE A DAY Cefdinir Oral Capsule 300 MG 300 MG ORALLY TWICE DAILY (ePrescribed by RESIDENT on Nov-01-2022 1620) Ezetimibe-Simvastatin Oral Tablet 10-40 MG 1 TAB ORALLY ONCE A DAY HYDROcodone-Acetaminophen Oral Tablet 5-325 MG Continue taking same as home Olmesartan Medoxomil-HCTZ Oral Tablet 40-12.5 MG 1 TAB ORALLY ONCE A DAY predniSONE Oral Tablet 10 MG 10 MG ORALLY ONCE A DAY (ePrescribed by RESIDENT on Nov-01-2022 1620) predniSONE Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY (ePrescribed by RESIDENT on Nov-01-2022 1620) predniSONE Oral Tablet 20 MG 40 MG ORALLY ONCE A DAY (ePrescribed by RESIDENT on Nov-01-2022 1620) predniSONE Oral Tablet 5 MG 5 MG ORALLY ONCE A DAY (ePrescribed by RESIDENT on Nov-01-2022 1620) Spiriva HandiHaler Inhalation Capsule 18 MCG 1 CAP INHALATION ONCE A DAY traMADol HCl Oral Tablet 50 MG Continue taking same as home Discharge Disposition Discharge to home with home health  Plan Assessment: -Sepsis (tachypnea, leukocytosis) secondary to COVID-19, present on admission,  resolved -Acute on chronic hypoxic and hypercapnic respiratory failure secondary to COVID-19 pneumonia,  acute exacerbation resolved -Acute exacerbation of COPD secondary to COVID-19 pneumonia,   improved -secondary bacterial pneumonia, community-acquired covered under ceftriaxone and azithromycin. - bacteremia versus contaminant,  2/4 bottles ( both from the same draw)  positive for Streptococcus salivarius -Heart failure with preserved ejection fraction, grade I diastolic dysfunction, possible acute decompensation,  improved -ICU delirium vs other altered mental status -Obstructive sleep apnea, BiPAP compliant at home,  may have some component of obesity hypoventilation syndrome -Acute kidney injury in the setting of CKD, Cr 2.6, secondary to sepsis; Cr 1.8 in August 2022,  resolved  AKI -Hyperkalemia, moderate, potassium 6.0 on admission, secondary to AKI, resolved -Hypernatremia, mild,  sodium 146 on 10/29/2022, likely due to fluid replacement within NS, resolved -Elevated troponin, likely  type 2 MI secondary to sepsis/respiratory failure and AKI,  improved -Essential hypertension,   Chronic, unknown control -Type 2 diabetes mellitus,  chronic, unknown control -Obesity class III, BMI 42 -Tobacco abuse disorder  PLAN: The patient was deemed stable and ready for discharge. The patient is currently saturating well on 4L NC, his baseline is 5L, at rest. Reasonable to titrate the patient off Precedex and deescalate his status from ICU to  PCU.  His agitation was noted to be most associated with the being constrained  in his room, lines, and being in the hospital. We re-evaluated the patient throughout the day and he remained calm and alert, without any agitation or confusion. Patient has showed no sign of being a danger to himself or others. We believe remaining agitation resolved once back  in his home environment.  We offered to discharge patient on Seroquel but patient and son declined. We recommended they have close follow up with PCP Dr. to ensure the he remains stable at home.   For treatment of pneumonia with possible concurrent bacteremia, we discharged the patient on cefdinir 300mg BID for 9 days to complete his course of ceftriaxone and azithromycin started while hospitalized.   Patient received methylprednisolone in the treatment of AECOPD/COVID. To ensure the patient does not suffer side effects upon discontinuing said IV steroids, we have discharged the patient on a prednisone taper described above in discharge medications. The taper was communicated to patient and family.    We recommend the patient follow-up closely with PCP  to monitor his acute illness and ICU associated delirium. We recommend a repeat BMP in 1 week to reassess hyperkalemia. We recommend patient completes his antibiotics.   The patient was seen and evaluated by attending Dr.,  and the plan of care discussed with this resident.     DO Family Medicine, PGY-2  Discharge Instructions Diet cardiac  carb consistent  Activity activity as tolerated  Follow up Appointments follow-up with PCP within the next 7 days  Primary Care Provider DO         DO  Electronically signed by PGY-1 on Nov-01-2022 2116 I have seen and physically examined the patient on [11-1-22] and agree with the documentation of [name of the resident]. I have also discussed my findings and plan of care with [name of the resident]. Any changes and additional information are listed below. Electronically signed by MD MD on Nov-02-2022 0838