Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Head injury, Hyperlipidaemia, Hypertension, Hypotension, Hypothyroidism
Clinical narrative: Date of Admission  01/19/2022   Date of Discharge  01/25/2022   Reason for Hospitalization   Sent from nursing home for difficulty breathing, increased O2 requirement. Normally on 3L, covid + yesterday. On arrival, Pt alert but not oriented. 98% on 3L. Reports fell yesterday and hit head, on eliquis and ASA.  Hospital Course   Patient is an 80 with COPD (baseline 3L), HFpEF (EF 65% on 11/2021), A. fib on Eliquis, hypothyroidism, recurrent UTIs, HTN, HLD, chronic back pain, MDD, GAD, constipation, and several recent admissions for COPD exacerbation and CAP (E. coli and Klebsiella in the past, Non-TB mycobacterial infection 11/2021), admitted with dyspnea and fatigue, known to be COVID+, treated for AKI and COPD exacerbation, currently stable for discharge home and follow up outpatient with PCP.   I have seen and examined the patient on day of discharge.  I counseled patient/caregiver on medications, side effects, discharge plan, and follow-up care.  I answered all questions.  Patient/caregiver voiced understanding.  Discharge Diagnoses      COVID     Hypotension     Orders:   acetaminophen, 500 mg = 1 Tablet(s), Oral, tid, Scheduled / PRN PRN as needed for pain, X 14 day(s), # 24 Tablet(s), Refill(s) 0, 02/08/22, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  albuterol, 180 = mcg 2 Puff, Inhalation, qid, PRN Shortness of Breath, # 18 g, Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  albuterol-ipratropium, 3 mL, Hi-Flow Neb, qid, Scheduled / PRN PRN Shortness of Breath, # 90 mL, Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  amLODIPine, 10 mg = 2 Tablet(s), Oral, Daily, # 60 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  apixaban, 5 mg 1 Tablet(s), Oral, bid, # 60 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  aspirin, 81 mg = 1 Tablet(s), Oral, Daily, # 30 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  atenolol, 100 mg = 1 Tablet(s), Oral, Daily, # 30 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  benzocaine-menthol topical, 1 Lozenge, Oral, q2h, Scheduled / PRN PRN Sore Throat, X 7 day(s), # 18 Each, Refill(s) 0, 02/01/22, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  DULoxetine, 60 mg = 1 capsule(s), Oral, Daily, # 30 capsule(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  fluticasone/umeclidinium/vilanterol, 1 Puff, Inhalation, Daily, # 1 Each, Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  furosemide, 40 mg = 1 Tablet(s), Oral, bid, # 60 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  gabapentin, 100 mg = 1 capsule(s), Oral, tid, # 90 capsule(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  levothyroxine, 125 mcg = 1 Tablet(s), Oral, Daily, # 30 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  lidocaine topical, 1 Patch, Topical, Daily, remove patches after 12 hours, # 30 Patch, Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  melatonin, 6 mg = 2 Tablet(s), Oral, At Bedtime, X 30 day(s), # 60 Tablet(s), Refill(s) 0, 02/24/22, Pharmacy: 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  metoclopramide, 5 mg = 1 Tablet(s), Oral, PC & Bedtime, X 30 day(s), # 120 Tablet(s), Refill(s) 0, 02/24/22, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  metoprolol, 100 mg = 2 Tablet(s), Oral, bid, # 120 Tablet(s), Refill(s) 0, Pharmacy: 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  mirtazapine, 15 mg = 1 Tablet(s), Oral, At Bedtime, # 30 Tablet(s), Refill(s) 0, Pharmacy: 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  nystatin topical, 1 Application, Topical, tid, Scheduled / PRN PRN Rash, X 30 day(s), # 15 g, Refill(s) 0, 02/24/22, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  ocular lubricant, 1 Drop(s), Each Eye, qid, Scheduled / PRN PRN Dry Eyes, # 56 Each, Refill(s) 0, Pharmacy: 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  pantoprazole, 40 mg = 1 Tablet(s), Oral, bid, # 60 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  polyethylene glycol 3350, 17 = g, Oral, Daily, X 30 day(s), # 12 Each, Refill(s) 0, 02/24/22, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  potassium chloride, 10 mEq = 1 Tablet(s), Oral, Daily, # 30 Tablet(s), Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  senna, 17.2 mg = 2 Tablet(s), Oral, bid, X 30 day(s), # 120 Tablet(s), Refill(s) 0, 02/24/22, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  sodium chloride nasal, 1 Spray, IntraNasal, qid, # 1 Each, Refill(s) 0, 165.1, cm, 01/25/22 6:06:00 CST, Height (cm), kg, 01/25/22 6:06:00 CST, Weight (kg), 83.3  Skin Care Team Dressing 2 Recommendations  Other Diagnoses   Ongoing  (HFpEF) heart failure with preserved ejection fraction  Abnormal MRCP - dilated CBD. Negative work-up/EUS  ANA positive  Anemia  Antral erosion  Arthritis  Atrial fibrillation  BMI 31.0-31.9,adult  Cervical spinal stenosis  Chronic GERD  Chronic insomnia  Chronic musculoskeletal pain  Colorectal polyp detected on colonoscopy  Constipation  COPD (chronic obstructive pulmonary disease) with emphysema  Diastolic heart failure  Dysphagia NOS  Ectropion  GAD (generalized anxiety disorder)  GERD with esophagitis  H/O hypokalemia  Hyperlipidemia  Hypertension  Hypothyroidism  Lower back pain  Lumbar spinal stenosis  MDD (major depressive disorder)  Migraine  Monoclonal gammopathy of unknown significance (MGUS)  Obesity  Opioid use agreement exists  Osteoarthrosis, Generalized  Osteoporosis  Panic disorder  Preventative health care  Recurrent falls  Recurrent pneumonia  Recurrent UTI  Sepsis  Situational insomnia  UNSPECIFIED HYPOTHYROIDISM  Historical  Anorexia  Anxiety  B12 deficiency  COPD - Chronic obstructive pulmonary disease  Eyelid lesion  Fall as cause of accidental injury at home as place of occurrence  HTN - Hypertension  Hypothyroidism  PTSD - Post-traumatic stress disorder  Right rib fracture  UNSPECIFIED FRACTURE OF ANKLE LEFT        Discharge Disposition  Home    Medications  New, Changed, or Refilled Medications  DULoxetine (DULoxetine 60 mg oral delayed 60 mg, 1 capsule(s), Oral, Daily, 30 capsule(s), 0 Refill(s)    acetaminophen (Tylenol Extra Strength 500 500 mg, 1 Tablet(s), Oral, tid, for 14 day(s), PRN: as needed for pain, 24 Tablet(s), 0 Refill(s)    albuterol (albuterol  HFA 90 mcg/inh inhal 180 mcg, 2 Puff, Inhalation, qid, PRN: Shortness of Breath, 18 g, 0 Refill(s)    albuterol-ipratropium (albuterol-ipratropi 3 mL, Hi-Flow Neb, qid, PRN: Shortness of Breath, 90 mL, 0 Refill(s)    amLODIPine (amLODIPine 5 mg) 10 mg, 2 Tablet(s), Oral, Daily, 60 Tablet(s), 0 Refill(s)    apixaban (Eliquis 5 mg) 5 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    aspirin (Aspirin Enteric Coated 81 mg oral 81 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    atenolol (atenolol 100 mg) 100 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    benzocaine-menthol topical (benzocaine-men 1 Lozenge, Oral, q2h, for 7 day(s), PRN: Sore Throat, 18 Each, 0 Refill(s)    fluticasone/umeclidinium/vilanterol (Trele 1 Puff, Inhalation, Daily, for 30 day(s), 1 Each, 0 Refill(s)    furosemide (furosemide 40 mg) 40 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    gabapentin (gabapentin 100 mg) 100 mg, 1 capsule(s), Oral, tid, 90 capsule(s), 0 Refill(s)    levothyroxine (levothyroxine 125 mcg (0.12 125 mcg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    lidocaine topical (Lidoderm 5% topical fil 1 Patch, Topical, Daily, remove patches after 12 hours, 30 Patch, 0 Refill(s)  Instructions:remove patches after 12 hours  melatonin (Melatonin 3 mg) 6 mg, 2 Tablet(s), Oral, At Bedtime, for 30 day(s), 60 Tablet(s), 0 Refill(s)    metoclopramide (metoclopramide 5 mg) 5 mg, 1 Tablet(s), Oral, PC & Bedtime, for 30 day(s), 120 Tablet(s), 0 Refill(s)    metoprolol (metoprolol tartrate 50 mg) 100 mg, 2 Tablet(s), Oral, bid, 120 Tablet(s), 0 Refill(s)    mirtazapine (mirtazapine 15 mg) 15 mg, 1 Tablet(s), Oral, At Bedtime, 30 Tablet(s), 0 Refill(s)    nystatin topical (Nystop 100,000 units/g t 1 Application, Topical, tid, for 30 day(s), PRN: Rash, 15 g, 0 Refill(s)    ocular lubricant (Artificial Tears ophthal 1 Drop(s), Each Eye, qid, PRN: Dry Eyes, 56 Each, 0 Refill(s)    pantoprazole (pantoprazole 40 mg oral dela 40 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    polyethylene glycol 3350 (polyethylene gly 17 g, Oral, Daily, for 30 day(s), 12 Each, 0 Refill(s)    potassium chloride (potassium chloride 10 10 mEq, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    senna (Geri-kot 8.6 mg) 17.2 mg, 2 Tablet(s), Oral, bid, for 30 day(s), 120 Tablet(s), 0 Refill(s)    sodium chloride nasal (sodium chloride 0.6 1 Spray, IntraNasal, qid, 1 Each, 0 Refill(s)      Medications to be Continued  calcium carbonate (Tums 500 mg , chewable) 500 mg, 1 Tablet(s), Oral, tid, for 30 day(s), PRN: Indigestion, 1 Tablet(s), 0 Refill(s)    calcium-vitamin D (calcium (as carbonate)- 1 Tablet(s), Oral, tid, 90 Tablet(s), 0 Refill(s)    clonazePAM (clonazePAM 1 mg) 1 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    ergocalciferol (ergocalciferol 1.25 mg (50 50,000 IntUnits, 1 capsule(s), Oral, qSaturday, 5 capsule(s), 0 Refill(s)    naloxone (Narcan 4 mg/0.1 mL nasal spray) 4 mg, IntraNasal, As Indicated, Use if signs of opioid overdose. Call 911. May repeat x 1., PRN: Opiate Reversal, 2 Each, 0 Refill(s)  Instructions:Use if signs of opioid overdose. Call 911. May repeat x 1.    Discontinued Medications  acetaminophen-HYDROcodone (acetaminophen-h 1 Tablet(s), Oral, q6h, PRN: as needed for pain, 30 Tablet(s), 0 Refill(s)    chlorthalidone (chlorthalidone 25 mg) 25 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 36.5 °C  TMIN: 36.4 °C  TMAX: 36.6 °C  HR: 64  RR: 18  BP: 151/76  SpO2: 100%  WT: 83.3 kg  BMI: 30.6      General: no acute distress Heart: regular rate and rhythm; normal S1 and S2 without murmur or gallop Lungs: clear to auscultation bilaterally Abdomen: soft nontender, BS active Musculoskeletal: moves all 4 extremities against gravity spontaneously. No LE swelling. Skin: warm, no rash Neuro: alert; no focal deficits Psych: normal affect  Time Spent   More than 32 minutes including final face to face visit with patient, discharge medication reconciliation and patient counseling, preparation of instructions for continuing care and completion of discharge summary.    Follow Up Appointments         With  When  Contact Information        follow up with PCP within 1 week of discharge Within 1 month   Additional Instructions: You must contact this provider to schedule your appointment.       Nursing/Other Orders   Regular Diet. Ordered on 01/19/22 18:22:00 CST, Meal Start Time Breakfast 0700 to 0900   Intake and Output. 01/19/22 15:45:15 CST, Continuous Order, q12h. Order comment: Ordered by system rule: ORD_ADD_CHF_TASKS based on indications for congestive heart failure.   Intake and Output (I&O). 01/19/22 18:22:00 CST, Continuous Order   Sofcare Static Air Seat Cushion. 01/19/22 19:40:00 CST, when out of bed to chair   Place pillow between knees when on side. 01/19/22 19:40:00 CST   Right Heel Suspension (Heel/s suspend, right). 01/19/22 19:40:00 CST, off of the bed with pillow, As Indicated   Left Heel Suspension (Heel/s suspend, left). 01/19/22 19:40:00 CST, off of the bed with pillow, As Indicated   Fall Precautions. 01/19/22 11:40:00 CST. Order comment: order placed from nursing documentation CLIN_FALL_RISK   Aspiration Precautions. 01/19/22 18:22:00 CST q24h   Fall Precautions. 01/19/22 18:22:00 CSTOrder comment: Assess Fall Risk Score Qday; Orientation/clarity/mental status;patient stability during ambulation/transfer (ie., gait, balance, streng ); Effectiveness of safety interventions    Activity As Tolerated. 01/19/22 18:22:00 CST, Continuous Order   Code Status. Code Status Description: Full Code