Date of Admission: 10/18/2023   Date of Discharge: 10/21/2023   Issues to be Addressed at Follow-up: 1. covid19 infection                - continues Paxlovid through 10/23/2023                - isolation through 10/24/2023                - don't resume Flomax until 10/25/2023 due to drug-drug interaction with Paxlovid   2. Low blood pressure ~ 90-100s: asymptomatic.                - Losartan stopped                - follow up with PCP     Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/21/2023 12:00 PM CBC W AUTOMATED DIFFERENTIAL In process --   10/21/2023 12:00 PM WBC AUTO DIFF In process --   10/21/2023 12:00 PM CBC + DIFF (FAC LAB). In process --   10/18/2023  6:18 PM BLOOD CULTURE 2 Preliminary BLOOD   10/18/2023  6:15 PM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? HYPOTENSION   ? HYPOMAGNESEMIA   ? SECONDARY THROMBOCYTOPENIA       5/25/2023 - Results    Probably due to cirrhosis  Lab Results Component Value Date   WBC COUNT 4.5 05/18/2023   Hgb 13.4 05/18/2023   Hematocrit 42.4 05/18/2023   Platelets count 63 (L) 05/18/2023   Platelets,bld,ql, man ct CONFIRMD 05/18/2023         ? OBSTRUCTIVE SLEEP APNEA       5/28/2022 - Chart Update   Date: 10/29/12  Study Type: WatchPAT  pAHI: 36.3  BMI: 30.28  Min SpO2: 87% SpO2<90%: 5.2 minutes  Severe Sleep Apnea. Date: 11/8/18  Study Type: WatchPAT  pAHI: 63.3  BMI: 29.44   ESS: 3  Min SpO2: 86% SpO2<90%: 93.7 minutes  Severe Sleep Apnea.     ? CAD W STABLE ANGINA   ? SEIZURE, GENERALIZED, 1ST, UNSPECIFIED TYPE       5/25/2023 - Chart Update    On keppra     ? HX OF DUODENAL ULCER       5/28/2022 - Chart Update   With history of acute bleeding. D/t over use ASA - EGD 12/16/12 with large duodenal ulcer in angle, white peripherally, black centrally; Clotest negative - EGD 12/18/12 with large amount of blood clot in stomach, semi-fresh blood in stomach, large duodenal ulcer in angle with clot - EGD 12/19/12 with 4 mm clean-based gastric antral ulcer, gastric antral erosions, large clean-based duodenal ulcer in angle - EGD 12/21/12 with 4 mm clean-based gastric antral ulcer, gastric antral erosions, large duodenal ulcer in angle with fresh clot suggestive of re-bleed EGD-2/15/23-1. Normal esophagus, no esophageal varices, gastroesophageal junction at 46cm.  2. Diffuse erythema with mosaic pattern of stomach, particularly in gastric body, likely portal hypertensive gastropathy, biopsied in the antrum and body to assess for Helicobacter Pylori.  3. Some scarring and patent/patulous pylorus.  4. Normal duodenum to second part.    ? HTN   ? ALCOHOLIC CIRRHOSIS       5/25/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.     Lab Results Component Value Date   ALT 33 05/18/2023    Lab Results Component Value Date   AST 55 (H) 05/18/2023   No alcohol since 2020 MELD score 7 Under GI care q 6 months labs and u/s recommended       Resolved Hospital Problems   Diagnosis Date Resolved ? SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION 10/19/2023     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Pt is a 76 y/o male with h/o obstructive sleep apnea, coronary artery disease, alcohol liver cirrhosis.     Admitted on 10/18/2023 for 2-3 days of generalized weakness and mild congestive, non-productive cough. Onset of symptoms ~ 10/15 Whole family + Covid19. Chest x-ray (-) Not hypoxic.   Found to have Covid19 (+) Started on Paxlovid on 10/19/2023.   Pt has been doing well after admission. Feels stronger. Did well with PT and no skill needs at discharge.   Some residual congestive cough. 02sat 94-96% and no steroid needed. Pt was ready to go home on 10/20/2023.    Pt continues to do well 10/21/2023 and eager to go home 10/21/2023. Discharge patient with additional Paxlovid to complete 5 days course on 10/23/2023. Hold Flomax while on Paxlovid (drug drug interaction.)   Of note during this admission, pt's systolic blood pressure was in 80s at admission and then improves to 90-100s. Asymptomatic. No dizziness.   Borderline low blood pressure at baseline. Would hold Losartan at discharge.                          ASSESSMENT AND PLANS   1. Covid19 infection Assessment:  ? Symptoms started ~ 10/15 ? Sick contact: whole family got covid ? Doing well clinically.   Plan(s): ? continues Paxlovid x 5 days - through 10/23/2023 ? Hold Flomax until 10/25/2023 ? Enhanced isolation through 10/24/2023 x 10 days ? Cough meds as needed   2. Hypotension  Assessment:  ? Systolic blood pressure 90-100s. ? asymptomatic Plan(s): ? Hold losartan for now ? Follow up with PCPP   3. Liver cirrhosis and chronic thrombocytopenia Assessment:  ? No acute problem Plan(s): ? On low dose of lactulose daily ? Lasix and aldactone daily ? Mg 1.6 - replace Mg and discharge with Mag oxide supplement 400mg/day   4. Other conditions  Assessment:  ? Coronary artery disease: platetlets 50K - not on Aspirin ? Hx duodenal ulcer: on pepcid ? Hx seizure: on Keppra   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Covid19 infection   Complications: none   Consults: PT Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR    HBS PROGRESS NOTE Hospital Day(s): 3 DNR   PPE in uses for this patient: ? Universal Precautions (Hand Hygiene & Gloves) ? Gown ? Isolation Mask  ? N95 ? Patient Masked: no    SUBJECTIVE   Residual congestive cough. No shortness of breath.  Ready to go home since yesterday.      OBJECTIVE BP 112/60  | Pulse 43  | Temp 97.7 °F (36.5 °C)  | Resp 18  | Wt 93 kg (205 lb 0.4 oz)  | SpO2 94%  | BMI 26.32 kg/m²  Temp (24hrs), Avg:97.3 °F (36.3 °C), Min:96.7 °F (35.9 °C), Max:97.7 °F (36.5 °C)     Oxygen: O2 Delivery: RA-Room Air (10/21/23 0920)     Intake/Output Summary (Last 24 hours) at 10/21/2023 1230 Last data filed at 10/20/2023 1729  Gross over last 24 hours Intake 240 ml Output ? Net 240 ml   No data found.      Physical Exam    Physical Examination   Gen: Alert and oriented x3.  NAD.   HEENT: EOMI Neck: supple Lungs: diminished BS at bases. No wheezing. Heart: s1s2 RRR. No murmur Abd: soft. Non tender. Ventral hernia. Non tender.  Ext: no edema.       Current hospital medications    Current Facility-Administered Medications Medication Dose Route Frequency Last Admin ? Benzonatate Capsule 100 mg (TESSALON PERLES)  100 mg Oral TID 100 mg at 10/21/23 0927 ? guaiFENesin 12Hr ER Tab 600 mg (MUCINEX)  600 mg Oral Q12H 600 mg at 10/21/23 0923 ? Midodrine tablet 2.5 mg (PROAMATINE)  2.5 mg Oral TID while awake 2.5 mg at 10/21/23 0919 ? Finasteride Tab 5 mg (PROSCAR)  5 mg Oral Daily 5 mg at 10/21/23 0924 ? COSOPT 22.3-6.8 mg/mL Eye Soln 1 Drop (Dorzolamide-Timolol)  1 Drop Right eye BID 1 Drop at 10/21/23 0926 ? Lactulose Oral Soln 15 g  15 g Oral Daily 15 g at 10/21/23 0927 ? Latanoprost 0.005 % Eye Soln 1 Drop (XALATAN)  1 Drop Both eyes QPM 1 Drop at 10/20/23 2114 ? LevETIRAcetam tablet 1,250 mg (KEPPRA)  1,250 mg Oral BID 1,250 mg at 10/21/23 0922 ? [Manual Hold] Tamsulosin capsule 0.8 mg (FLOMAX)  0.8 mg Oral Daily   ? Chlorhexidine Gluconate Oral Soln 15 mL (PERIDEX)  15 mL Oral Q12H 15 mL at 10/21/23 0927 ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS Q8H while awake 3 mL at 10/21/23 0926 ? Melatonin Tab 3 mg (MELATIN)  3 mg Oral Q24H 3 mg at 10/20/23 2147   Or ? Melatonin Tab 3 mg (MELATIN)  3 mg Nasogastric Q24H   ? Famotidine Tablet 20 mg (PEPCID)  20 mg Oral BID 20 mg at 10/21/23 0923 ? Sennosides Tab 8.6 mg (SENOKOT)  8.6 mg Oral BID 8.6 mg at 10/21/23 0927 ? PAXLOVID co-packaged 3 tablet (Nirmatrelvir-Ritonavir)  3 tablet Oral Q12H (INPT RN check 1st dose) 3 tablet at 10/21/23 0952      Current Facility-Administered Medications Medication Dose Route Frequency Last Rate Last Admin      Current Facility-Administered Medications Medication Dose Route Frequency Last Admin ? Albuterol 90 mcg/actuation HFA MDI 2 Puff (PROAIR/PROVENTIL/VENTOLIN)  2 Puff Inhalation Q4H PRN   ? Lidocaine 10 mg/mL (1 %) Inj 1 mg (Xylocaine)  0.1 mL Intradermal PRN   ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS PRN   ? [Manual Hold] traZODone Tab 50 mg (DESYREL)  50 mg Oral QHS PRN     Or ? [Manual Hold] traZODone Tab 50 mg (DESYREL)  50 mg Nasogastric QHS PRN   ? Ondansetron (PF) Inj 4 mg (ZOFRAN)  4 mg intraVENOUS Q6H PRN   ? Metoclopramide Inj 5 mg (REGLAN)  5 mg intraVENOUS Q6H PRN   ? Acetaminophen Tablet 650 mg (TYLENOL)  650 mg Oral Q4H PRN 650 mg at 10/20/23 0032   Or ? Acetaminophen Supp 650 mg (TYLENOL)  650 mg Rectal Q4H PRN   ? oxyCODONE IR Tab 2.5 mg (ROXICODONE)  2.5 mg Oral Q6H PRN 2.5 mg at 10/19/23 0035   Or ? HYDROmorphone Inj Syg 0.1 mg (DILAUDID)  0.1 mg intraVENOUS Q2H PRN              Selected Results    Hospital labs Selected Lab Results: Electrolytes  Recent Labs   10/21/23 0642 10/20/23 0755 10/19/23 0740 NA 138 137 137 K 4.4 3.7 4.2 CO2 20* 24 27 CL 105 104 103 BUN 11 10 11 CR 0.71 0.77 0.83 RBS 105 115 134 MG 1.6*  --   --    CBC  Recent Labs   10/20/23 0755 10/19/23 0740 10/18/23 1818 WBC 4.0 3.2* 5.6 HGB 12.6* 12.3* 13.9 HCT 38.8* 37.9* 42.5 PLT 51* 53* DECREASE* | 77* | NORMAL MCV 104* 105* 102* NEUT 61 72 85 LYMPH 25 | 1.0 13 | 0.4* 5 | 0.3* MONO 0.4 | 11 0.4 | 13 0.4 | 7 EOS 0 | 0.0 1 | 0.0 1 | 0.1   LFTs  Recent Labs   10/21/23 0642 10/20/23 0755 10/19/23 0740 AST 100* 104* 80* ALT 38 40 37 ALKP 76 76 81 TBILI 0.7 0.8 1.0         Covid test  Lab Results Component Value Date/Time   CORONAVIRUS COVID DETECTED (A) 10/18/2023 06:15 PM   CORONAVIRUS COVID NOT DETECTED 11/29/2021 04:02 PM   CORONAVIRUS COVID NOT DETECTED 09/20/2021 02:07 PM   CORONAVIRUS COVID NOT DETECTED 06/26/2021 11:00 AM   CORONAVIRUS COVID NOT DETECTED 12/28/2020 09:54 AM   CORONAVIRUS COVID NOT DETECTED 12/21/2020 04:12 PM     Unresulted labs  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/21/2023 12:00 PM CBC W AUTOMATED DIFFERENTIAL In process --   10/21/2023 12:00 PM WBC AUTO DIFF In process --   10/21/2023 12:00 PM CBC + DIFF (FAC LAB). In process --   10/18/2023  6:18 PM BLOOD CULTURE 2 Preliminary BLOOD   10/18/2023  6:15 PM BLOOD CULTURE Preliminary BLOOD          Note Details  Author (M.D.) File Time 10/21/2023 12:37 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Admit Date 10/18/2023  ED to Hosp-Admission (Discharged) on 10/18/2023  ED to Hosp-Admission (Discharged) on 10/18/2023   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   HTN  ALCOHOLIC CIRRHOSIS  SEIZURE, GENERALIZED, 1ST, UNSPECIFIED TYPE  CAD W STABLE ANGINA  COVID-19 PNEUMONIA  SEVERE SEPSIS W ACUTE ORGAN DYSFUNCTION Resolved  SECONDARY THROMBOCYTOPENIA  HX OF DUODENAL ULCER  HYPOTENSION  OBSTRUCTIVE SLEEP APNEA  HYPOMAGNESEMIA Care Timeline  10/18   Admitted from ED (Observation) 2203 10/21   Discharged 1505  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 10/21/2023) Medication List at Discharge   albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply is 1 canister  benzonatate 100 mg Oral 3 TIMES A DAY AS NEEDED  dorzolamide HCl/timolol maleat 22.3-6.8 mg/mL 1 Drop Right eye 2 TIMES A DAY  finasteride 5 mg Oral DAILY  fluorouracil 5 % Apply to affected area(s) 2 times a day for 6 weeks on and around biopsy site of the scalp. Expect redness, peeling, irritation, and skin that sunburns more easily. For severe reaction, stop for 1 to 2 days, then resume. Avoid contact with eyes or with skin that is not being treated. Unless treating hands, wash hands with soap and water after use.  furosemide 20 mg Oral DAILY  guaifenesin 600 mg Oral EVERY 12 HOURS  lactulose   15 g Oral DAILY  10 gram/15 mL Soln, Take 15 mL by mouth 3 times a day as needed for fatigue or confusion.  latanoprost 0.005 % Instill 1 drop in both eyes daily at bedtime for glaucoma. Refrigerate unopened bottles. Once opened, may store at room temperature for up to 6 weeks  levetiracetam   250 mg Tab, Take 1 tablet by mouth 2 times a day . Total dose 1250 mg orally twice daily  1,000 mg Tab, Take 1 tablet by mouth 2 times a day. Total dose 1250mg orally 2 times daily.  magnesium oxide 400 mg Oral DAILY  metformin HCl 1,000 mg Oral 2 TIMES A DAY WITH MEALS  multivitamin 1 tablet Oral DAILY  nirmatrelvir/ritonavir 300 mg (150 mg x 2)-100 mg Take 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) by mouth 2 times a day for 3 days through 10/23/2023  spironolactone 25 mg Oral DAILY  tamsulosin HCl 0.8 mg Oral DAILY, . Take 30 minutes after dinner or before bed.  Don't take while you are taking Paxlovid for Covid19 infection. Resume Flomax on 10/25/2023.