Date of Admission: 8/23/2023   Date of Discharge: 8/30/2023   Issues to be Addressed at Follow-up: Continue the antibiotics through 9/6 Physical therapy   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 7/31/2023 to 8/31/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) GANGRENE OF RIGHT TOE   ? LONG TERM NON WARFARIN ORAL ANTICOAGULANT THERAPY       Dabigatran (Pradaxa) 150mg BID Indications:  Non-valvular Atrial fibrillation/Flutter  Expected length of therapy: Indefinite (Provider to assess risk vs benefits periodically)  Considerations:             ? DM 2       Started in 2008. Fasting blood sugars 140-170.  Basename Value Date/Time ? HGBA1C %    7.9 08/25/2016 . 02/07/2013  DM2 wo retinopathy resolved   ? HYPOCALCEMIA   ? OSTEOMYELITIS OF LEFT FOOT       Added automatically from request for surgery   ? COVID-19 DISEASE   ? SEVERE PERSISTENT ASTHMA   ? MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION   ? ATRIAL FIBRILLATION, PAROXYSMAL   ? CAD WO ANGINA, PRESENCE OF STENT       2/16/19: DES to RCA   ? ANXIETY DISORDER DUE TO ANOTHER MEDICAL CONDITION   ? DM 2 W CHARCOT ARTHROPATHY   ? ATHEROSCLEROSIS OF AORTA   ? DM 2 W ULCER OF LEFT FOOT   ? HYPERLIPIDEMIA        Basename Value Date/Time ? CHOLESTEROL       149 08/05/2014 ? TRIGLYCERIDE      195 08/05/2014 ? HDL                37 08/05/2014 ? LDL CALCULATED     73 08/05/2014   On lovastatin   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? HTN     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: The patient is a 72 years old woman with history of diabetes mellitus type 2, hypertension, hyperlipidemia, severe peripheral vascular disease, left foot Charcot arthropathy, GERD, asthma, atrial fibrillation on Pradaxa, depression, residing with her daughter who acts as the main caretaker, who presented on 8/23 with gangrene of the right toe, and was found to have osteomyelitis. The culture from the wound was polymicrobial, with main pathogen being Morganella. Enterococcus was also found.   The patient was treated with intravenous Zosyn and vancomycin, and eventually had a first ray amputation on the right, with subsequent closure of the wound.   In the operating podiatrist opinion, the area of osteomyelitis has been completely removed.   Weightbearing as tolerated and physical therapy assessment was recommended.  The patient was felt to be able to come home with home health PT.   On admission, the patient was found to be COVID-19 positive (onset of symptoms was 8/18).  Although never symptomatic, she has received 5 days total course of intravenous remdesivir, keeping in mind her comorbidities.  She was deisolated on 8/28.   Patient's daughter reported being symptomatic for COVID-19 as well (now de-isolated and symptoms free).   Per discussion with infectious disease service, patient's vancomycin has been stopped. It was felt reasonable to cover with IV antibiotics for 10 days starting the date of surgery. Rocephin IV for Morganella, and Augmentin for Enterococcus were recommended.   A midline was placed, and well-tolerated by the patient. She had no apparent issues with the antibiotics regimen.   The patient had on-and-off sundowning, likely related to the use of Morphine/oxycodone. These symptoms resolved. The above agents were replaced by Tramadol, as needed for severe pain (rarely used).   The patient is AAO x 3 at the time of d/c, but she is somewhat forgetful. Her daughter is her DPOA, and the primary caretaker.   The patient has history of severe asthma, which has been controlled on Fasenra injections. The next one is scheduled in the clinic around 9/20   Patient's daughter reported her being occasionally hypotensive at home. The BP control regimen was reviewed and adjusted.   Primary Procedures:  Procedure(s): FIRST RAY AMPUTATION, HALLUX, COMPLETE OR PARTIAL EXTREMITIES LAYER CLOSURE OF WOUNDS   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Gangrene of the R toe   Complications: none   Consults:  PODIATRY - INITIAL INPATIENT CONSULTATION. PODIATRY - ONGOING INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  File Time 8/30/2023 12:43 PM Author Type Physician Status Signed Admit Date 8/23/2023  ED to Hosp-Admission (Discharged) on 8/23/2023  ED to Hosp-Admission (Discharged) on 8/23/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  FIRST RAY AMPUTATION, HA From 8/23/2023 to 8/24/2023 FIRST RAY AMPUTATION, HA From 8/24/2023 to 8/28/2023 FIRST RAY AMPUTATION, HA From 8/25/2023 to 8/28/2023  Hospital Problem List   HTN  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  HYPERLIPIDEMIA  DM 2 W ULCER OF LEFT FOOT  ATHEROSCLEROSIS OF AORTA  DM 2 W CHARCOT ARTHROPATHY  ANXIETY DISORDER DUE TO ANOTHER MEDICAL CONDITION  CAD WO ANGINA, PRESENCE OF STENT  ATRIAL FIBRILLATION, PAROXYSMAL  SEVERE PERSISTENT ASTHMA  MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION  GANGRENE OF RIGHT TOE  OSTEOMYELITIS OF LEFT FOOT  COVID-19 DISEASE  HYPOCALCEMIA  LONG TERM NON WARFARIN ORAL ANTICOAGULANT THERAPY  DM 2 Care Timeline  08/23   Admitted from ED 1837 08/25   FIRST RAY AMPUTATION, HALLUX, COMPLETE OR PARTIAL 08/27   FIRST RAY AMPUTATION, HALLUX, COMPLETE OR PARTIAL 08/30   Discharged 1635  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 8/30/2023)   Follow-Ups: Follow up with SNF Medication List at Discharge   acetaminophen   650 mg Oral EVERY 4 HOURS AS NEEDED, . Do not exceed 10 tablets in 24 hours. Do not exceed 4,000 mg of acetaminophen per day from all sources  650 mg Oral EVERY 4 HOURS AS NEEDED, (temperature > 100.4). Do not exceed 10 tablets in 24 hours. Do not exceed 4,000 mg of acetaminophen per day from all sources  albuterol sulfate   2.5 mg /3 mL (0.083 %) Neb soln, Use 1 vial via nebulizer every 4 hours when needed for asthma  90 mcg/actuation Hfaa, 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply for asthma is 1 canister  amoxicillin/potassium clav 875-125 mg 1 tablet Oral EVERY 12 HOURS  benralizumab   30 mg Subcutaneous Outpatient (Back Office), INJECT 30 MG SUBCUTANEOUSLY EVERY 8 WEEKS X 6 MONTHS **SUBCUTANEOUS use only** Do NOT withhold/discontinue metoprolol. OK to give if BP < 160/100 mm Hg.  30 mg Subcutaneous EVERY 8 WEEKS, as directed. Start at Week 16, next administration is on, or around 9/20  bisacodyl 10 mg 1 Suppository Rectal DAILY AS NEEDED, . Use as 2nd line treatment if 1st line treatment is ineffective  blood pressure test kit-large Use at home to check BP  blood sugar diagnostic 1 Strip Miscell. (Med.Supl.;Non-Drugs) 4 TIMES A DAY, to measure blood sugar  blood-glucose control, normal Use as directed with blood glucose meter  blood-glucose meter Use as directed to test blood sugar  bupropion HCl 150 mg Oral 2 TIMES A DAY  ceftriaxone in is-osm dextrose 2 gram/50 mL 2 g intraVENOUS EVERY 24 HOURS  clopidogrel bisulfate 75 mg Oral DAILY  dabigatran etexilate mesylate 150 mg Oral 2 TIMES A DAY, . Take with a full glass of water. Do not break, chew, or open capsule  diclofenac sodium 1 % Apply 2 Grams to affected area(s) 2 times a day as needed for hand pain  docusate sodium 250 mg Oral DAILY, for bowel regularity. Hold for loose stools  dorzolamide HCl/timolol maleat 22.3-6.8 mg/mL 1 Drop Both eyes 2 TIMES A DAY, for Glaucoma  epinephrine 0.3 mg/0.3 mL Inject 0.3 mL intramuscularly as needed for severe allergic reaction . Inject into thigh at the first sign of severe allergic reaction or as directed  famotidine 40 mg Take one-half tablet by mouth about 30 minutes before eating food or drinking beverages that cause heartburn. Do not exceed 1 tablet in 24 hours. Take with a full glass of water  fluticasone propionate   50 mcg/actuation Spsn, 1 Spray Each nostril 2 TIMES A DAY  220 mcg/actuation Hfaa, 1 Puff Inhalation 2 TIMES A DAY  glucagon 1 mg If receiving insulin and signs or symptoms of hypoglycemia are present, give snack. If patient is not responsive to snack, give glucagon subcutaneously or intramuscularly and notify physician on-call. Recheck glucose in 15 minutes  insulin regular, human 100 unit/mL If BG <60 & alert give snack, check BG w/in 30 min, hold insulin. Call MD if unresponsive. If BG 60-149 do not give insulin; If BG 150-199 give 2 units; 200-249 give 4 units; 250-299 give 6 units; 300-349 give 8 units; 350-399 give 10 units; 400-449 give 12 units; >450 give 14 units & check in 2 hrs & notify MD/NP if glucose still >450  ipratropium bromide 17 mcg/actuation 2 Puffs Inhalation 4 TIMES A DAY AS NEEDED  isosorbide mononitrate   15 mg Oral EVERY MORNING  15 mg Oral EVERY MORNING  L. acidophilus/L.bulgaricus 1 million cell 1 tablet Oral 2 TIMES A DAY, while on antibiotics in SNF  lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) 4 TIMES A DAY, to measure blood sugar  losartan potassium 50 mg Oral DAILY  metoprolol tartrate 12.5 mg Oral 2 TIMES A DAY  multivitamin TAKE 1 TABLET ORALLY DAILY  nitroglycerin 0.4 mg Dissolve 1 tablet under the tongue as needed for chest pain , may repeat 2 times at 5 minute intervals. Call EMS if the pain persists longer than 5 minutes after the first dose. Continue to take the 2nd and 3rd dose if pain persists  nystatin 100,000 unit/gram Topical 2 TIMES A DAY  pantoprazole sodium 40 mg Take 1 tablet by mouth 30 minutes before breakfast and 30 minutes before dinner for 8 weeks  prazosin HCl 1 mg Oral 2 TIMES A DAY  rosuvastatin calcium 40 mg Oral DAILY, to prevent heart attacks and strokes  sennosides 8.6 mg Take 1 tablet by mouth with each narcotic dose for bowel regularity. Do not exceed 8 tablets in 24 hours. Hold for loose stools  sucralfate 1 g Oral 4 TIMES A DAY  tizanidine HCl 4 mg Oral 3 TIMES A DAY AS NEEDED  tramadol HCl 50 mg Oral EVERY 6 HOURS AS NEEDED  trazodone HCl 25 mg Oral EVERY BEDTIME  zafirlukast 20 mg Take 1 tablet by mouth 2 times a day . Special Order Item: Allow 5 Working Days. pt is not vacinated