Age: 60.0
Sex: F
Vaccine: COVID19
Symptoms: Scleroderma, Sepsis, Septic shock, Serum ferritin normal, Tachycardia
Clinical narrative: Date of Admission: 9/25/2023   Date of Discharge: 9/30/2023   Issues to be Addressed at Follow-up: + HTN management, adjust lisinopril or adding back norvasc as needed + follow up final blood cultures + remove midline once done with ertapenem + monitor diarrhea. Patient with C. Diff, on po vanco taper + monitor left shoulder wound, probably had an abscess, which has been draining with less output now + ? Visual hallucination? If reoccur, may consider stopping remeron + medications review         Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/25/2023  1:35 AM BLOOD CULTURE Preliminary BLOOD   9/25/2023  1:15 AM BLOOD CULTURE 2 Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? IRRITABLE BOWEL SYNDROME       Reported by family   ? CKD STAGE 3B (GFR 30-44)   ? HEMIPLEGIA, LEFT NONDOMINANT SIDE       See note on 8/16/2023   For Diagnosis prompt, please delete, modify at PCP's discretion     ? UTI (URINARY TRACT INFECTION)   ? SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION   ? HX OF EMBOLIC STROKE   ? ANEMIA       4/18/2023 - Chart Update    Lab Results Component Value Date   Iron 69 12/08/2022   Total iron binding capacity 282 12/08/2022   Ferritin 105 12/08/2022   Transferrin % saturation 24 12/08/2022 has been taking iron daily colonoscopy in 2018 fhx of colon cancer.  Recent EMERGENCY ROOM visit Last Admit Date: 04/04/2023 with Hb of 6.6. Was admitted - 1PRBC transfusion. Had EGD and Colonscopy.    Plan Discussed can take over the counter iron QOD. Hb 8.4 today  - stable for now Advised patient to email/call if any worsening/recurrence of sympts noted. EMERGENCY ROOM precautions discussed            ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? DM 2 W PERIPHERAL NEUROPATHY   ? IDIOPATHIC PULMONARY FIBROSIS   ? SCLERODERMA, UNSPECIFIED   ? OBSTRUCTIVE SLEEP APNEA       WATCHPAT AMBULATORY SLEEP STUDY       5/16/16   Diagnosis:    SEVERE OSA (AHI= 46; ODI = 32, Min O2 sat 77%; Mean O2 sat =93%; Duration o2 Sat <90% = 18 minutes) ESS = 14 Estimated body mass index is 30.04   ? HX OF LUNG TRANSPLANT       Double lung transplant 4/3/2011 UCSF. Donor age 14.   Last Assessment & Plan:  Formatting of this note might be different from the original. This patient is physiologically stable after an apparent intercurrent viral respiratory illness.  The patient's viral studies were negative.  She has a benign physical exam.  Her cough is mild and decreasing.  The patient is scheduled for three-year surveillance on April 1.  She will have spirometry and imaging if indicated at that time.   ? HX OF C DIFFICILE       10/14/2022  Symptoms of loose stools in the last 1 weeks- intermittent. Watery diarrhea for a day and then normal stools.  No fever or chills No pain in the abdomen.  Had loose stools 2am to 5am.  Feels normal except for the intermittent loose stools. No blood in stool. Feels it could be food related.  Discussed not to take imodium. Order placed for the stool studies. Understands to do this if she has 4 or more loose stools in a day.  Advised patient to email/call if any worsening/recurrence of sympts noted.     8/9/2022   First episode  Tested C. Diff PCR positive. Had several loose stools and abdominal cramps prior to testing.  On vancomycin. States she has improved less number of stools. More mushy and not watery. Feels more gas+.  No blood in stool. Plan Discussed high fiber diet Continue medications. Advised patient to email/call if any worsening/recurrence of sympts noted.       7/19/2022   immunocompromised - due to medications. Hx of transplant Symptoms of intermittent ongoing stomach aches since early July. Had some fever and loose stools and abdominal pain. Symptoms are better now. Continues to have some discomfort in the abdomen and loose stools Had 4 loose stools yesterday. No blood in stool or black stools or mucous in stool. Imodium helps. covid test was negative Used to be on mag but not anymore. Was told told to stop due to loose stools   Plan Given persistent symptoms Stool studies Plan HIGH FIBER DIET and probiotics Has appointment with Transplant team too Advised patient to email/call if any worsening/recurrence of sympts noted.       ? HTN (HYPERTENSION)       4/18/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.    BP Readings from Last 3 Encounters: 04/18/23 130/49 04/05/23 125/53 03/21/23 111/44         ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)       *PROTONIX 40MG EC TABLETS               1 BID       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  SNF   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Per dr. note Patient is a 63 Y female with recent admission for sepsis due to UTI (8/15 - 8/18), then GI bleed (8/10 - 8/13), and CVA s/p TNK and mechanical thrombectomy with left sided hemiparesis (7/12 - 7/20) with hospitalization complicated by Klebsiella MDR bacteremia leading to septic shock, hx of C diff, Hypertension, idiopathic pulmonary fibrosis s/p lung transplant on immunosuppressants, scleroderma, DM 2, and CKD 3 admitted with sepsis with COVID 19 (now on RA), with diarrhea (with CDiff recurrence) and UTI   Plan:  - discharge to SNF tomorrow after Bezlotoxumab X 1 dose  -  continue PO vancomycin 125mg 4 times daily (- 10/10/23), then two times daily (10/11- 10/24/23), then daily (10/25- 10/31/23) then every 3 days for 6-8 weeks - continue Ertapenem 1 g daily X 3 more days (9/25- 10/01/23) via midline       Assessment and Plan:   Patient Active Hospital Problem List: SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION (8/16/2023)  UTI (URINARY TRACT INFECTION) (8/16/2023) - Immunosuppressed with recurrent MDR UTI. Presented with low BP and tachycardia from SNF, now stable vitals.  - Urine culture with ESBL Klebsiella aerogenes . Blood culture NGTD   Plan:  - continue Ertapenem , end date: 10/1 - follow up final blood culture      RECURRENT C. DIFF  HX OF C DIFFICILE (2/9/2010) - Doing better, no more diarrhea   - ID recommended Monoclonal antibody therapy with bezlotoxumab X 1 dose  given immunosuppressed state , which was given 9/29   Plan:  - continue PO vancomycin 125mg 4 times daily ( 9/27- 10/10/23), then two times daily ( 10/11- 10/24/23), then daily (10/25- 10/31/23) then every 3 days for 6-8 weeks     VISUAL HALLUCINATION - patient is not on narcotics. Symptom occurred while getting Bezlotoxumab. ? Due to this med? Patient is also on Remeron, which could potentially cause visual hallucination but per UPTODATE, it's only < 1% of risk, also patient has been on this  - patient is a&ox 3 otherwise, no new focal deficit - no more visual hallucination - plan: continue monitor for now. Melatonin qhs      COVID-19 DISEASE (2/11/2021) -  Noted on admission. On RA - s/p remdesivir x 3 days - not on dexamethasone as on home prednisone    Plan:  - covid precautions until 10/15/2023 given immunosuppression      SHOULDER ABSCESS -  Noted on wound care evaluation with pus drainage. .3 x 0.3 x 2 cm - patient reported that this wound was "lanced" prior to this admit - per most recent wound care note on 9/29, "scant serosanguienous exudate. Minimal drainage noted when removing dressing. No odor or purulent drainage noted" Plan: - continue wound care, monitor the wound. Been on Ertapenem - if worsening, consider surgery consult        IDIOPATHIC PULMONARY FIBROSIS (8/9/2018)  HX OF LUNG TRANSPLANT (8/24/2011)  SCLERODERMA, UNSPECIFIED (6/2/2016) -  noted   Plan:  - continue mycophenolate, prednisone and tacrolimus, dapsone and valganciclovir      SEVERE PROTEIN CALORIE MALNUTRITION -  Poor PO intake and weight loss since CVA. - plans: continue supplements,  Vitamin C, calcium carbonate      HX OF EMBOLIC STROKE (7/12/2023)  HEMIPLEGIA, LEFT NONDOMINANT SIDE (9/1/2023) -  noted  . Left side flaccid Plan:  - continue plavix - not on statin outpatient       HTN (HYPERTENSION) (11/9/2009)  TYPE 2 MI (9/25/2023)   - noted. Was on lisinopril 2.5mg daily and norvasc 2.5mg daily at home - BP slightly on the high side   Plan:  - up  lisinopril to 5mg daily. Continue monitor, adjust med as needed        DM 2 W PERIPHERAL NEUROPATHY (1/11/2019)     Assessment:           Lab Results Component Value Date   Hgb A1c % 5.1 06/07/2023            Lab Results Component Value Date   GLUCOSE, RANDOM 97 09/28/2023     - had hypoglycemia, NPH was reduced   Plan:  - Continue NPH 5u qam,  ISS, ADA - Continue optimization as outpatient        NONTRAUMATIC ACUTE KIDNEY INJURY (4/7/2020) CKD STAGE 3B (GFR 30-44) (9/12/2023) -  Baseline Cr ~ 0.82. AKI resolved with IVF - plan: continue monitor     ANEMIA (8/9/2022)   - noted. Baseline Hb 7-9   Plan:  - continue Fe, folic acid. Continue monitor at SNF       GERD (GASTROESOPHAGEAL REFLUX DISEASE) (5/25/2006)  - continue PPI       OBSTRUCTIVE SLEEP APNEA (5/16/2016)  - CPAP PRN        .  Complications: none   Consults:  None   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code      Note Details  Author Do, (D.O.) File Time 9/30/2023  1:57 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor Do, (D.O.) Specialty Hospital Medicine Hospital Acct # Admit Date 9/25/2023  ED to Hosp-Admission (Discharged) on 9/25/2023  ED to Hosp-Admission (Discharged) on 9/25/2023   Detailed Report  Note shared with patient Hospital Problem List   GERD (GASTROESOPHAGEAL REFLUX DISEASE)  HTN (HYPERTENSION)  HX OF LUNG TRANSPLANT  OBSTRUCTIVE SLEEP APNEA  SCLERODERMA, UNSPECIFIED  IDIOPATHIC PULMONARY FIBROSIS  DM 2 W PERIPHERAL NEUROPATHY  HEMIPLEGIA, LEFT NONDOMINANT SIDE  CKD STAGE 3B (GFR 30-44)  COVID-19 DISEASE  HX OF C DIFFICILE  NONTRAUMATIC ACUTE KIDNEY INJURY  ANEMIA  HX OF EMBOLIC STROKE  UTI (URINARY TRACT INFECTION)  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION  IRRITABLE BOWEL SYNDROME Care Timeline  09/25   Admitted from ED (Observation) 0540 09/27   Admitted 0838 09/30   Discharged 1643  Discharge   SNF - Skilled bed (or Subacute)   AVS  1 Discharge Instructions (AVS) (Printed 9/30/2023) 2 SNF Orders (Printed 9/30/2023)