Discharge Provider: DO Primary Care Provider: DO Admission Date: 9/1/2022 Discharge Date: Sep 7, 2022   PRESENTING PROBLEM: Platelets decreased (HCC) [D69.6] Atrial fibrillation with RVR (HCC) [I48.91] Pancytopenia (HCC) [D61.818] Hypoxia [R09.02]   HOSPITAL COURSE: The patient is a very pleasant 83 y/o married community dwelling patient of doctor who was admitted for evaluation of hypoxia and A fib with RVR as well as Pancytopenia.     The patient's hypoxia was secondary to both COVID pneumonia, secondary bacterial pneumonia, as well as acute congestive heart failure related to A fib with RVR.  The patient's hypoxia resolved at discharge with treating the above.  RT50 on day of discharge showed no supplemental oxygen needs with ambulation and rest.     The patient's COVID 19 was treated with steroids and not Remdesivir.  The patient received IV antibiotics as well.     His heart rate was controlled with both his home dose of beta blocker as well as addition of Cardizem which will be continued at discharge including Cardizem CD 120 mg PO daily.  The patient's anticoagulation including coumadin was held during this admission d/t the thrombocytopenia and bleeding.  The patient's coumadin was restarted the day prior to discharge when his platelets and hemoglobin were stable after the transfusions for several days.  The patient's CHADSVASC score was significantly elevated.  The patient understood that with his newly diagnosed blood disoroder (as described below) that there was a risk of bleeding which could be treated with tranfusion and stopping the anticoagulation, but he also understood his high risk of stroke with having a fib and no anticoagulation.  He wanted to assume the bleeding risk and wanted to be back on anticoagulation.  He will follow up with his coumadin clinic to get his INR at goal to 2-3.   The patient's pancytopenia was monitored during this admission.  The patient received 3 units of pRBC's as well as 1 unit of platelets.  His hemoglobin and platelet count was stable for several days after the transfusion.  He had a flow cytometry study as recommended by a phone consultation by hematology that was abnormal for possible myelodysplastic syndrome or acute myeloid leukemia.  We do not have inpatient hematology or oncology consults available.  I had a phone consultation on 9/6 with doctor who was on call who said that because the WBC was nml and not significantly elevated, that the patient didn't need a BM biopsy in the next 1-2 days, but that an outpatient evaluation in the next few weeks would be helpful.     I reached out to hematology oncology clinic who said that they could do a consult, but do not do bone marrow biopsies at that facility.  They asked that I refer to a cancer hematology referral line to get an appointment.  They asked for a DC summary and a referral form and a demographic sheet be sent to their referral fax number and that they would have their hematologist review this referral to determine how quickly the patient needs to be seen.  So, unfortunately, he didn't have an appointment at the time of discharge despite the doctor's wishes.  Our case manager is faxing the above requested items to the above number with any further referral forms that they need to be obtained by his PCP's office.     I spoke with the doctor about this as well as the patient going back on Coumadin.  The patient will have a follow up labs next Monday including a CBC to follow up on the pancytopenia and a BMP from the resolved AKI.   I spoke with the doctor also about the CT findings of ? Cholangiitis, but we both agreed that patient had no manifestations of this illness, but he will continue to monitor for this.    Thank you for the privilege of taking care of the patient.