Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Glycosylated haemoglobin increased, Hyperlipidaemia, Hypertension, Hypoxia
Clinical narrative: Date of Admission: 10/15/2023   Date of Discharge: 10/17/2023   Addendum: 10/18/23   Issues to be Addressed at Follow-up: + follow up final blood cultures + post covid follow up : on RA + medications review + repeat noncon chest CT in 12 months to follow up pul nodule + follow up    Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/15/2023  2:59 AM BLOOD CULTURE 2 Preliminary BLOOD   10/15/2023  2:59 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? MEDIASTINAL LYMPHADENOPATHY       Per CT on 10/12/23 -   "  Nonspecific nonenlarged and borderline enlarged mediastinal and hilar lymph nodes, possibly reactive in etiology given reported history of cough, however neoplastic etiology cannot be excluded.  Incidental 0.3 cm right upper lobe nodule .  Solid lung nodule(s) </= 5 mm in an upper lobe and/or spiculated. Recommendation: If patient is low risk for lung cancer, no follow-up CT. Otherwise, low dose noncontrast chest CT in 12 months." - plan: patient to follow up with PCP with repeat noncon CT chest in 12 months per recommendation     ? SINUS TACHYCARDIA   ? SOLITARY PULMONARY NODULE       CTA 10/12/23 3 mm, repeat CT in 12 months   ? CHRONIC LOW BACK PAIN W LUMBAR RADICULOPATHY       6/25/2021 MD- DOV Under control with prn ibuprofen 800mg. No redflag signs.        ? ATHEROSCLEROSIS OF AORTA       Seen on CXR 1/2017, on statin   ? DM 2 W HYPERLIPIDEMIA       6/25/2021 MD- DOV Uncontrolled with max dose of glipizide and metformin. Likes to eat desserts and rice is part of diet. Walks 2 miles a day. Not checking glc daily    Basename Value Date/Time ? HGBA1C % 9.5 (H) 06/17/2021   A/P: does not want insulin at this time; would like to improve diet, increase walking miles/day, and check glc at home with target of 80-140. Gave phone number to pharmacy team so that he can reach out and have closer monitoring.        ? HTN (HYPERTENSION)       6/25/2021 MD: Chronic established diagnosis. Briefly reviewed plan today, continue current regimen.     Basename Value Date/Time ? CREATININE   0.98 06/17/2021    Basename Value Date/Time ? POTASSIUM    3.7 06/17/2021         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:   Background  67M with history of DM, HTN, presented with shortness of breath, cough and fever x 1 week . Tested positive for COVID on 10/12/23. In Ed, found to have hypoxia and admitted for further management. Treated w/ RDV and decadron w/ supportive therapy. Eventually titrated off supplemental oxygen and discharged to home in stable condition.   General appearance - alert  , in no acute distress   Mental Status - alert, oriented x 3    Chest -   clear to ascultation bilateral  Heart - regular   rate and rhythm  Abdomen - soft, nontender  , non distended  Neurological - motor and sensory   grossly normal bilaterally  Extremities - no clubbing, cyanosis   Skin - warm and dry     Ct chest  Impression  Negative for pulmonary embolism.    No focal airspace consolidation.    Nonspecific nonenlarged and borderline enlarged mediastinal and hilar lymph nodes, possibly reactive in etiology given reported history of cough, however neoplastic etiology cannot be excluded.    Incidental 0.3 cm right upper lobe nodule.   Solid lung nodule(s) </= 5 mm in an upper lobe and/or spiculated. Recommendation: If patient is low risk for lung cancer, no follow-up CT. Otherwise, low dose noncontrast chest CT in 12 months.        Action required. +                   Assessment and Plan:   COVID 19 - titrated off O2, has prn O2 available at home  - CXR with bilateral opacities, which is new compared to the CXR done on 10/12/23 - completed 4d of RDV and decadron, no longer requiring given pt is not hypoxic  - spo2 96% on RA on oxywalk   SINUS TACHYCARDIA - most likely due to acaute respiratory failure/ distress. EKG with sinus tachycardia, similar to previous studies. No PE on CT done on 10/12    LUNG NODULE BORDERLINE MEDIASTINAL & HILAR LNs - per CT on 10/12 "  Nonspecific nonenlarged and borderline enlarged mediastinal and hilar lymph nodes, possibly reactive in etiology given reported history of cough, however neoplastic etiology cannot be excluded.  Incidental 0.3 cm right upper lobe nodule .  Solid lung nodule(s) </= 5 mm in an upper lobe and/or spiculated. Recommendation: If patient is low risk for lung cancer, no follow-up CT. Otherwise, low dose noncontrast chest CT in 12 months." - per patient, he stopped smoking 27years ago.  - plan: patient to follow up with PCP with repeat noncon CT chest in 12 months per recommendation . Patient was made aware of this     HTN (HYPERTENSION) -Continue home amlodipine and losartan       DM 2     Assessment:           Lab Results Component Value Date   Hgb A1c % 7.1 (H) 08/28/2023            Lab Results Component Value Date   GLUCOSE, RANDOM 132 10/16/2023     Plan:  -  Continue glipizide, Resume metformin at home   - Continue optimization as outpatient   HYPERLIPIDEMIA  ATHEROSCLEROSIS OF AORTA - resume statin at discharge      CHRONIC LOW BACK PAIN W LUMBAR RADICULOPATHY   LUMBAR SPONDYLOSIS -Tylenol as needed     Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code        Note Details  Author (M.D.) File Time 10/19/2023  2:39 PM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 10/15/2023  ED to Hosp-Admission (Discharged) on 10/15/2023  ED to Hosp-Admission (Discharged) on 10/15/2023   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   DM 2 W HYPERLIPIDEMIA  HTN (HYPERTENSION)  ATHEROSCLEROSIS OF AORTA  COVID-19 DISEASE  CHRONIC LOW BACK PAIN W LUMBAR RADICULOPATHY  SOLITARY PULMONARY NODULE  SINUS TACHYCARDIA  MEDIASTINAL LYMPHADENOPATHY Care Timeline  10/15   Admitted from ED (Observation) 1558 10/18   Discharged 1720  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/18/2023) Medication List at Discharge   acetaminophen 500 mg 1 p.o daily  albuterol sulfate 90 mcg/actuation Inhale 2 puffs by mouth one-half hour before sports or exercise to prevent cough or wheezing. May repeat every 4 hours as needed for cough or wheezing. 100 days supply is 1 canister  amlodipine besylate 10 mg Oral DAILY  aspirin 81 mg Oral DAILY  atorvastatin calcium 40 mg Oral EVERY EVENING  empagliflozin 12.5 mg Oral DAILY  Patient not taking:  Reported on 5/30/2023  glipizide 10 mg Oral 2 TIMES A DAY BEFORE BREAKFAST AND DINNER  guaifenesin 200 mg Oral EVERY 4 HOURS AS NEEDED  hydrocortisone   2.5 % Oint, Topical 2 TIMES A DAY, for 10 to 14 days  Patient not taking:  Reported on 5/30/2023  2.5 % Crea, Apply to affected area(s) 2 times a day as needed for rash . OK to use on face, neck or skin folds. Avoid long-term use near eyes. Stop when rash is gone  ibuprofen 800 mg Oral 3 TIMES A DAY AS NEEDED, . Take with food  inhaler, assist devices Use as directed with inhaler  ketotifen fumarate 0.025 % (0.035 %) 1 Drop Ophthalmic 2 TIMES A DAY  losartan potassium 75 mg Oral DAILY  metformin HCl 1,000 mg Oral 2 TIMES A DAY, with food  olopatadine HCl 0.1 % 1 Drop Ophthalmic 2 TIMES A DAY