Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Acquired diaphragmatic eventration, Aortic valve replacement, Atrial fibrillation, Atrial flutter, COVID-19
Clinical narrative: Date of Admission: 10/14/2023   Date of Discharge: 10/17/2023   Issues to be Addressed at Follow-up: #ATRIAL FLUTTER #HX OF AORTIC VALVE REPLACEMENT #HX OF THORACIC AORTA REPAIR - cont Metoprolol 100mg bid and Digoxin 0.125mg po daily for rate control; hold if HR<60 or SBP<90 - complete digoxin level in 5-7 days - follow-up with cards outpatient on 11/3 - cont Coumadin as dosed per anticoagulation clinic; goal INR 2-3 - repeat INR in 2 days - cont Colchicine 0.6mg po daily for post-thoracotomy syndrome    #ELEVATION OF LEFT HEMIDIAPHRAGM - as seen on latest CXR - thought to be secondary to phrenic nerve from recent surgeries - continue to monitor HR and BP for eventual resolution   #COVID POSITIVE #COUGH - found to be Covid+ on admission - must isolate for an additional 10 days at home - dextromethorphan for cough prn   #HX OF PANCREATITIS - diagnosed recently as likely c/b recent cardiac surgeries; worse after meals - cont Tylenol po 650mg q4h prn for pain - cont Protonix po 40mg daily - follow-up with GI outpatient   #HTN - con Carvedilol #PTSD - cont home Lexapro and Trazadone 50mg qhs     Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/15/2023  8:13 PM ERYTHROCYTE SEDIMENTATION RATE, AUTOMATED In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ATRIAL FLUTTER, CHRONIC W PROTHROMBOTIC STATE   ? HX OF AORTIC VALVE REPLACEMENT, BIOPROSTHETIC   ? HX OF AORTIC ROOT REPAIR   ? PLEURAL EFFUSION     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 73 Y male with PMH of PTSD, HTN, MGUS, anemia, multiple vascular aneurysms, and recent thoracic aorta repair and AV replacement (8/23/23) at Hospital for 45 days c/b acute SBO, pancreatitis (10/3), afib, and now rapid afib s/p cardioversion (9/17/23) to NSR followed by Amiodarone as maintenance. He then presented to doctor on 10/14/23 due cc of palpitations and found to have atrial flutter with HR>120s and given fluids and 3 doses of Metoprolol 5mg w/o improvement. Dr. (cards) and Dr. (CT surgeon) were consulted to present options for alternative rate-control medications however, patient's wife refused until they discussed with his team to ensure they were all in mutual agreement of the plan. The decision was later made to increase the Metoprolol dose to 50mg BID -- > TID in order to avoid starting any new medications given that the wife was reluctant to do so due to his pancreatitis. Patient was also started on Coumadin due to his recent AV repair surgery. Digoxin was eventually added for further rate control and starting colchicine 0.6mg daily for post-thoracotomy syndrome as seen on latest echo c/b large pleural effusion and smaller pericardial effusion so given time to resolve on its own before considering giving Lasix due to worsening renal insufficiency 2/2 his poor oral intake. Per staff, a large pleural effusion w/o evidence of cardiac tamponade, and normal EF. Given that the patient has been asymptomatic otherwise, and monitor for changes.A repeat CXR found a slightly abnormal way the diaphragm was oriented. Later discharge that patient home same day.     Primary Procedures:      Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  #ATRIAL FLUTTER   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. CARDIOLOGY - INITIAL INPATIENT CONSULTATION. CARDIOLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     Subjective on Day of Discharge:   Objective on Day of Discharge: Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 10/17/23 1732 ? ? ? 109/85 ? ? ? 10/17/23 1050 ? ? 108 96/80 ? ? ? 10/17/23 0901 ? ? 130 106/86 ? ? ? 10/17/23 0852 98 °F (36.7 °C) Oral 130 106/86 25 95 % RA 10/17/23 0650 97.9 °F (36.6 °C) Oral 118 102/83 20 97 % RA 10/16/23 2355 97.8 °F (36.6 °C) Oral 107 103/80 20 95 % RA 10/16/23 2135 ? ? 98 ? ? ? ?     Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregular.     Heart sounds: No murmur heard.    No friction rub.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: No wheezing or rales.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.       ____________________________ Dr. D.O.      Cosigned by: M.D. at 10/21/2023 11:20 PM  Note Details  Author D.O. File Time 10/21/2023 11:20 PM Author Type PHYSICIAN, RESIDENT Status Signed Last Editor D.O. Specialty GENERAL, OTHER Admit Date 10/14/2023  ED to Hosp-Admission (Discharged) on 10/14/2023  ED to Hosp-Admission (Discharged) on 10/14/2023   Revision History   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   HX OF AORTIC VALVE REPLACEMENT, BIOPROSTHETIC  HX OF AORTIC ROOT REPAIR  PLEURAL EFFUSION  ATRIAL FLUTTER, CHRONIC W PROTHROMBOTIC STATE Care Timeline  10/14   Admitted from ED (Observation) 2003 10/17   Discharged 1917  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 10/17/2023)   Discharge Orders - Labs  BICARBONATE  BUN  CRP (C-REACTIVE PROTEIN)  ERYTHROCYTE SEDIMENTATION RATE, AUTOMATED  CHLORIDE  CREATININE W GFR, CALCULATED  GLUCOSE  MAGNESIUM  POTASSIUM  SODIUM  PT ...(9 more)  Discharge Orders - Other Orders  EKG 12 OR MORE LEADS W INT & RPT  Medication List at Discharge   acetaminophen 650 mg Oral EVERY 4 HOURS AS NEEDED, . Do not exceed 8 tablets in 24 hours  benzonatate 100 mg Oral 3 TIMES A DAY  colchicine 0.6 mg Oral DAILY  diclofenac sodium 4 g Topical 2 TIMES A DAY AS NEEDED  digoxin 125 mcg Oral DAILY  escitalopram oxalate 5 mg Oral DAILY  metoprolol tartrate 100 mg Oral 2 TIMES A DAY  NON-SYSTEM (SEE ADMIN INSTR) 1,000 mg Oral DAILY, Vitamin B 12 chew 2 gummies daily   pantoprazole sodium 40 mg Oral DAILY BEFORE BREAKFAST, Contact PCP for all refills  tramadol HCl 50 mg Take one-half tablet by mouth every 6 hours as needed for severe pain Patient currently tolerating on this admission. Start to Wean ASAP within 24 hours by increasing times between doses. Patient to notify surgeon's office if refill is needed.  trazodone HCl 50 mg Oral EVERY BEDTIME  warfarin sodium 2.5 mg Take as directed by physician or Anticoagulation clinic