Date of Admission: 10/18/2023   Date of Discharge: 10/21/2023   Issues to be Addressed at Follow-up: 1. Covid19 infection                - back to baseline 02 supplement - resume 02 supplement as needed at home                - therefore, not discharge on steroid                - isolation through 10/25/2023 (10 days from 10/16/2023)   2. HFrEF:                - acute on chronic HFrEF decompensation                - now euvolemic or slightly prerenal with BUN 30 -- > 60s on IV Lasix                - resume home dose of Lasix 40mg BID on Monday 10/23/2023 (hold Lasix tomorrow 10/22/2023)                - recheck chem7 in 30 days (home health RN to draw)       Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/18/2023  2:50 PM BLOOD CULTURE Preliminary BLOOD   10/18/2023  2:00 PM LACTIC ACID In process --   10/18/2023  2:00 PM BLOOD CULTURE 2 Preliminary BLOOD   10/18/2023 11:42 AM PT In process --   10/18/2023 11:42 AM DRAW AND HOLD PLASMA, CITRATE TUBE In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 ACUTE BRONCHITIS   ? CHRONIC RESPIRATORY FAILURE       Has 02 supplement at night as needed   ? ACUTE ON CHRONIC HYPOXEMIC RESPIRATORY FAILURE   ? SYSTOLIC HEART FAILURE, ACUTE ON CHRONIC       11/4/2022 - Chart Update   Seen cardiologist He suggested trying a low dose of Entresto and continuing diuresis with furosemide. I would suggest switching the Isosorbide mononitrate to Isordil 10 mg three times daily.  Potentially, Jardiance could be added subsequently. Toprol may be continued and increased as tolerated up to 100 mg daily. 10/26/22 ECHO ?  Left Ventricle: Left ventricle is moderately dilated. Severely reduced systolic function with a visually estimated EF of less than 20%. ?  Right Ventricle: Normal systolic function. ?  Aortic Valve: Mild aortic regurgitation. ?  Mitral Valve: Mild mitral regurgitation. ?  Tricuspid Valve: Mild tricuspid regurgitation. The PASP is estimated to be 27 mmHg which is normal.   ECHO:12/21  LV systolic function is severely decreased with a visually estimated  ejection fraction of 20-25%.     ? CKD STAGE 4 (GFR 15-29)       12/30/2021 - Chart Update    Lab Results Component Value Date   GLOMERULAR FILTRATION RATE - AFRICAN AMERICAN 25 (L) 12/17/2021   Glomerular filtration rate, nonAfrican American 22 (L) 12/17/2021         ? INTERMITTENT ALLERGIC ASTHMA, CONTROLLED   ? TYPE 2 MI   ? PRESENCE OF BIVENTRICULAR AICD         Biventricular ICD Biotronik Model:  Biotronik 429532 Rivacor 7 HF-T QP DF4 IS4 Date of implant:  2/8/22 Patient is not pacemaker dependent Instruction for surgery:  1. Place magnet over device during surgery MRI conditional leads: yes   MRI conditional device: yes  (See eConsult page "MRI for pacemaker pts" under Cardiology for info about MRI in patients with cardiac implanted electronic devices) Date last Updated: 2/16/2022     Additional notes: None     ? CAD WO ANGINA, W HX OF MI   ? HX OF ISCHEMIC STROKE       12/30/2021 - Chart Update     11/2012  PER DC SUMMARY presented to hospital with acute onset left sided weakness with facial droop. Patient  Had normal CT head and abnormal MRI showing lacunar infarct in the posterior limb of her MCA distribution.      ? HTN     Resolved Hospital Problems   Diagnosis Date Resolved ? SEPSIS WO ACUTE ORGAN DYSFUNCTION 10/19/2023     Discharge Disposition:  Board and Care   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Pt is 84 y/o female with hx of severe HFrEF (LVEF <20% per cardiac echo 10/2022) s/p AICD, coronary artery disease, asthma, chronic respiratory failure (has home 02 as needed), asthma, hypertension, hypertensive chronic kidney disease stage 4 (baseline Cr 1.6s-1.8s)   Onset of symptoms ~ 10/16/2023: generalized weakness with mild cough. Sick contact son (who lives with patient.) Tested Covid19 (+) on 10/18/2023 in the ED. Chest x-ray +bibasilar patchy opacities and mild central pulmonary vascular congestion.  BNP 1,058. 02sat 89% at room air and placed on 2LNC.   Admitted for acute on chronic respiratory failure due to Covid19 and some component of acute on chronic HFrEF decompensation.   Started on Remdesivir and Decadron 10/18 - 10/21/2023 & IV lasix.    Generalized weakness has improved and PT recommended home health. Good appetite.    The last 48 hours, 02sat 95-97% on 2LNC 02 supplement and at time, pt was off 02 supplement and her 02sat ~ 94%. Lungs sound clear on exam. No peripheral edema.   Repeated chest x-ray negative for pleural effusion or infiltrate.   Pt is discharged and quarantine x 10 days through 10/25/2023.   She was slightly prerenal on IV Lasix - her BUN trended up from 30s to 60s and Cr 1.9s (upper range of her baseline Cr.) Would hold Lasix on 10/22/2023 and recheck chem7 in about 3 days.   Refer to home health RN/PT.     Of note, during this admission, palliative care updated POLST to DNR.    Updated pt's daughter over the phone.     ASSESSMENT AND PLANS   1. Covid19 infection  - hx of asthma - back to her baseline chronic respiratory failure - use 02 supplement as needed. Assessment:  ? Onset symptoms ~ 10/16 ? Tested positive 10/18 ? Sick contact: son ? 10/20 - 10/21: doing well clinically.  Minimal cough.  No wheezing on exam. Lungs are clear.   Plan(s): ? S/p 4 days of Remdesivir & Decadron 10/18 - 10/21/2023 ? Given her respiratory status and 02 needed back to baseline: no Decadron at discharge. ? Enhanced isolation through 10/25/2023   2. Acute on chronic HFrEF decompensation.  Assessment:  ? Demand ischemic with mildly elevated HS-troponin: no chest pain ? Now slightly prerenal given elevated BUN ? 10/20 - 10/21: lungs sound clear, no peripheral edema and chest x-ray is clear.   Plan(s): ? Hold Lasix on 10/22/2023 and resume on Monday 10/23/2023. ? Recheck chem7 in about 3 days. ? Follow up with PCP   3. Other conditions Assessment:  ? Chronic kidney disease: Cr stable <2.0.  Monitor while on Lasix. ? Hypertension, coronary artery disease, hx CVA ? On Norvasc, Hydralazine/nitrate, Metoprolol XL, Aspirin, Plavix. ? Presence of AICD - no acute problem   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Covid19 infection Acute on chronic HFrEF decompensation   Complications: none   Consults: PT, palliative care   Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR    HBS PROGRESS NOTE Hospital Day(s): 3 DNR   CONSULTANTS     ? PT ? Palliative care              PPE in uses for this patient: ? Universal Precautions (Hand Hygiene & Gloves) ? Gown ? Isolation Mask  ? N95 ? Patient Masked: no    SUBJECTIVE   Feels good. Ready to go home. No shortness of breath. No cough today.       OBJECTIVE BP 123/64  | Pulse 60  | Temp 97.9 °F (36.6 °C)  | Resp 18  | Ht 5' 1"  | Wt 74.3 kg (163 lb 12.8 oz)  | SpO2 95%  | Breastfeeding No  | BMI 30.95 kg/m²  Temp (24hrs), Avg:98.4 °F (36.9 °C), Min:97.9 °F (36.6 °C), Max:98.6 °F (37 °C)     Oxygen: O2 Delivery: RA-Room Air (10/21/23 0851) nasal cannula @ 2LNC     Intake/Output Summary (Last 24 hours) at 10/21/2023 1149 Last data filed at 10/21/2023 0641  Gross over last 24 hours Intake 920 ml Output 500 ml Net 420 ml   Patient Vitals for the past 72 hrs:    Stool Characteristics Unmeasured Stool (#) 10/20/23 1200 Reported per Patient;Brown;Formed;Medium 1 10/19/23 2040 Brown;Large;Formed 1 10/19/23 1428 Brown;Medium;Soft 1          Physical Exam    Physical Examination   Gen: Alert and oriented to self, place. NAD.   HEENT: EOMI.   Neck: supple. Lungs: CTAB. No wheezing or crackles.  Heart: s1s2 RRR. No murmur. Abd: soft. Non tender.  Ext: no edema.        Current hospital medications    Current Facility-Administered Medications Medication Dose Route Frequency Last Admin ? Pharmacy Renal Per Protocol  1 Each Miscell. (Med.Supl.;Non-Drugs) see instruction   ? Heparin Porcine Inj Syg 5,000 Units  5,000 Units Subcutaneous Q12H 5,000 Units at 10/21/23 0854 ? Remdesivir Inj 100 mg (VEKLURY)  100 mg intraVENOUS Q24H 100 mg at 10/21/23 1054 ? THEREMS MULTIVITAMIN 1 tablet (Multivitamin with folic acid)  1 tablet Oral Daily 1 tablet at 10/21/23 0855 ? Aspirin Chew Tablet 81 mg  81 mg Oral Daily 81 mg at 10/21/23 0854 ? Atorvastatin Tab 40 mg (LIPITOR)  40 mg Oral QHS 40 mg at 10/20/23 2232 ? Clopidogrel Tab 75 mg (PLAVIX)  75 mg Oral Daily 75 mg at 10/21/23 0857 ? Cyanocobalamin Tab 500 mcg (VITAMIN B-12)  500 mcg Oral Daily 500 mcg at 10/21/23 0857 ? Metoprolol Succinate 24hr SR Tab 100 mg (TOPROL XL)  100 mg Oral Daily 100 mg at 10/21/23 0857 ? Pantoprazole TBEC DR Tablet 20 mg (PROTONIX)  20 mg Oral Daily before Breakfast 20 mg at 10/21/23 0856 ? Fluticasone 50 mcg/actuation Nasal Inhaler 2 Spray (FLONASE ALLERGY RELIEF)  2 Spray Each nostril Daily 2 Spray at 10/21/23 1053 ? Chlorhexidine Gluconate Oral Soln 15 mL (PERIDEX)  15 mL Oral Q12H 15 mL at 10/21/23 0856 ? Sodium Chloride 0.9% Inj Syg 3 mL (NORMAL SALINE FLUSH)  3 mL intraVENOUS Q8H while awake 3 mL at 10/21/23 0640 ? Insulin Lispro Sliding Scale Inj (HumaLOG)   Subcutaneous TID with meals and HS 1 Units at 10/20/23 1735 ? Flu Vaccine QS 2023-24 (65 yrs up) PF IM Syg 0.7 mL (FLUZONE HIGHDOSE QUAD)  1 Each intraMUSCULAR Prior to Discharge   ? Melatonin Tab 3 mg (MELATIN)  3 mg Oral Q24H 3 mg at 10/20/23 2044 ? Albuterol 90 mcg/actuation HFA MDI 2 Puff (PROAIR/PROVENTIL/VENTOLIN)  2 Puff Inhalation Q4H while awake (INPT RN check 1st dose) 2 Puff at 10/21/23 0830 ? dexAMETHasone Tab 6 mg (DECADRON)  6 mg Oral Daily (INPT RN check 1st dose) 6 mg at 10/21/23 0855   Or ? dexAMETHasone Sodium Phosphate Inj 6 mg (DECADRON)  6 mg intraVENOUS Daily (INPT RN check 1st dose)   ? amLODIPine Tab 5 mg (NORVASC)  5 mg Oral Daily 5 mg at 10/21/23 0856 ? Isosorbide Mononitrate 24hr SR Tab 120 mg  120 mg Oral QAM 120 mg at 10/21/23 0857 ? hydrALAZINE Tab 50 mg (APRESOLINE)  50 mg Oral TID 50 mg at 10/21/23 0855      Current Facility-Administered Medications Medication Dose Route Frequency Last Rate Last Admin      Current Facility-Administered Medications Medication Dose Route Frequency Last Admin ? Acetaminophen Tablet 1,000 mg (TYLENOL)  1,000 mg Oral Q6H 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   ? WEB LINK HYPOGLYCEMIA  1 Each Miscell. (Med.Supl.;Non-Drugs) Per protocol - multiple doses   ? D50W Inj Syg 12.5 g  25 mL intraVENOUS Per protocol - multiple doses   ? D50W Inj Syg 25 g  50 mL intraVENOUS Per protocol - multiple doses   ? Glucagon Inj 1 mg (GLUCAGEN DIAGNOSTIC KIT)  1 mg intraMUSCULAR Per protocol - multiple doses   ? D5W IV Premix  100 mL/hr intraVENOUS Per protocol - multiple doses   ? Metoclopramide Inj 5 mg (REGLAN)  5 mg intraVENOUS Q6H PRN   ? Lactulose Oral Soln 20 g  30 mL Oral BID PRN   ? Bisacodyl TBEC DR Tab 5 mg (DULCOLAX)  5 mg Oral Daily PRN     Or ? Bisacodyl Supp 10 mg (DULCOLAX)  10 mg Rectal Daily PRN              Selected Results    Hospital labs Selected Lab Results: Electrolytes  Recent Labs   10/21/23 0654 10/20/23 0705 10/19/23 0743 NA 135 137 139 K 4.1 4.2 4.3 CO2 22* 24 25 CL 100 101 103 BUN 65* 48* 36* CR 1.96* 1.74* 1.63* RBS 88 93 120 CA  --   --  9.9 PHOS  --   --  4.7* MG 2.1 2.1 2.3   CBC  Recent Labs   10/21/23 0654 10/20/23 0705 10/19/23 0743 WBC 6.5 5.7 4.5 HGB 12.9 12.6 12.1 HCT 41.3 40.3 39.4 PLT 206 165 155 MCV 90 90 91 NEUT 68 64 78 LYMPH 24 | 1.5 20 | 1.2 13 | 0.6* MONO 0.5 | 8 0.9 | 16 0.4 | 9 EOS 0 | 0.0 0 | 0.0 0 | 0.0   Cardiac  Recent Labs   10/19/23 1045 10/19/23 0743 10/19/23 0157 TROP 51* 48* 64*   LFTs  Recent Labs   10/21/23 0654 10/20/23 0705 10/19/23 1045 AST 25 20 24 ALT 12 9 10 ALKP 74 67 77 TBILI 0.5 0.6 0.6   ABG  Recent Labs   10/18/23 1536 PH 7.47* PO2 62* PCO2 35       Covid test  Lab Results Component Value Date/Time   CORONAVIRUS COVID DETECTED (A) 10/18/2023 12:50 PM   CORONAVIRUS COVID NOT DETECTED 10/26/2022 02:30 AM   CORONAVIRUS COVID NOT DETECTED 02/04/2022 10:00 AM   CORONAVIRUS COVID NOT DETECTED 12/17/2021 10:40 PM   CORONAVIRUS COVID NOT DETECTED 08/24/2021 11:56 PM   CORONAVIRUS COVID NOT DETECTED 07/15/2021 11:38 AM   CORONAVIRUS COVID NOT DETECTED 07/04/2021 04:13 PM     Unresulted labs  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/18/2023  2:50 PM BLOOD CULTURE Preliminary BLOOD   10/18/2023  2:00 PM LACTIC ACID In process --   10/18/2023  2:00 PM BLOOD CULTURE 2 Preliminary BLOOD   10/18/2023 11:42 AM PT In process --   10/18/2023 11:42 AM DRAW AND HOLD PLASMA, CITRATE TUBE In process --            Note Details  Author (M.D.) File Time 10/21/2023 11:50 AM 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 Hospital Problem List   CAD WO ANGINA, W HX OF MI  CKD STAGE 4 (GFR 15-29)  CHRONIC RESPIRATORY FAILURE  COVID-19 ACUTE BRONCHITIS  SYSTOLIC HEART FAILURE, ACUTE ON CHRONIC  PRESENCE OF BIVENTRICULAR AICD  ACUTE ON CHRONIC HYPOXEMIC RESPIRATORY FAILURE  SEPSIS WO ACUTE ORGAN DYSFUNCTION Resolved  TYPE 2 MI  HTN  INTERMITTENT ALLERGIC ASTHMA, CONTROLLED  HX OF ISCHEMIC STROKE Care Timeline  10/18   Admitted from ED (Observation) 1951 10/20   Admitted 0837 10/21   Discharged 1426  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 10/21/2023)   Discharge Orders BICARBONATE BUN CHLORIDE CREATININE W GFR, CALCULATED POTASSIUM SODIUM