Date of Service Jul-15-2022 0613  Addendum Additional Plan: - Patient will be discharged home. - Resume activity as tolerated. - Resume cardiac diet.      Electronically signed by (name withheld) on Jul-15-2022 1636 Date of Admission Admit Date: Jul-09-2022  Date of Discharge Date of discharge Jul-15-2022  Allergies Sulfa Antibiotics - Not Specified  Chief Complaint cough  Lab Results Jul-15-2022 0523 Serology PROCALC  <0.05 Jul-15-2022 0523 Hematology WBC  5.9RBC  2.25HGB  7.1HCT  21.2MCV  94.2MCH  31.6MCHC  33.5RDW  25.1RDWSD  81.2PLT  201MPV  12.5AUTONEU%  74.8AUTOLYM%  10.8AUTOMON%  13.2AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  4.4AUTOLYM#  0.6AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.06IG%  1.0 Jul-15-2022 0523 Chemistry GLUCOSE  99BUN  23CREAT  0.9MDRD GFR  60NA  136K  3.8CL  103CALCIUM  7.8CO2  25.8OSMO  275.7ANION GP  11.0BUN/CRE  25.6CRP  2.60 Jul-14-2022 0740 Hematology OCCBLDF  Pos Jul-14-2022 0700 Serology PROCALC  0.06 Jul-14-2022 0700 Hematology WBC  6.1RBC  1.94HGB  6.3HCT  19.3MCV  99.5MCH  32.5MCHC  32.6RDW  24.5RDWSD  82.5PLT  205MPV  12.2AUTONEU%  76.4AUTOLYM%  9.0AUTOMON%  13.1AUTOEOS%  0.2AUTOBAS%  0.2AUTONEU#  4.7AUTOLYM#  0.6AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.07IG%  1.1 Jul-14-2022 0700 Chemistry GLUCOSE  98BUN  24CREAT  0.9MDRD GFR  60NA  135K  3.6CL  101CALCIUM  8.0CO2  27.7OSMO  274.1ANION GP  9.9BUN/CRE  26.7 Jul-14-2022 0445 Urinalysis Department SPECGRAV  1.015U-PH  6.0LEUCOCYT  LargeNITRITES  NegativePROTEIN  30GLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  ModerateCOLOR  YellowCLARITY  ClearMICROSCP  YCULTURE  YWBC  Tntc Jul-14-2022 0445 Microbiology C UR  Identification and susceptibility to follow (Preliminary) Jul-13-2022 0405 Reference Lab ABIDARC  See Comment Jul-13-2022 0405 Blood Bank ABO  ARH  PosAB SC  PosD COOMBS  NegCROSS #1  CompCROSS#2  Comp Jul-13-2022 0345 Serology PROCALC  0.06 Jul-13-2022 0345 Hematology WBC  6.7RBC  1.98HGB  6.4HCT  19.7MCV  99.5MCH  32.3MCHC  32.5RDW  24.4RDWSD  85.2PLT  175MPV  11.2AUTONEU%  83.3AUTOLYM%  7.8AUTOMON%  7.8AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  5.6AUTOLYM#  0.5AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.06IG%  0.9 Jul-13-2022 0345 Chemistry GLUCOSE  101BUN  28CREAT  1.2MDRD GFR  43NA  133K  3.8CL  100CALCIUM  7.4CO2  29.2OSMO  272.0ANION GP  7.6BUN/CRE  23.3CRP  1.30 Jul-12-2022 0655 Hematology WBC  4.7RBC  2.20HGB  7.0HCT  21.9MCV  99.5MCH  31.8MCHC  32.0RDW  25.1RDWSD  86.5PLT  181MPV  11.0AUTONEU%  73.5AUTOLYM%  13.1AUTOMON%  12.8AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  3.4AUTOLYM#  0.6AUTOMON#  0.6AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.02IG%  0.4 Jul-12-2022 0655 Chemistry GLUCOSE  90BUN  21CREAT  1.0MDRD GFR  53NA  134K  3.4CL  99CALCIUM  7.5CO2  28.5OSMO  270.7ANION GP  9.9BUN/CRE  21.0CRP  1.10 Jul-11-2022 0840 Coagulation D-DIMER  1.76 Jul-11-2022 0548 Hematology WBC  5.0RBC  2.29HGB  7.4HCT  22.1MCV  96.5MCH  32.3MCHC  33.5RDW  25.4RDWSD  85.0PLT  216MPV  13.3AUTONEU%  75.8AUTOLYM%  10.2AUTOMON%  13.0AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  3.8AUTOLYM#  0.5AUTOMON#  0.7AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.04IG%  0.8 Jul-11-2022 0548 Chemistry GLUCOSE  84BUN  17CREAT  0.9MDRD GFR  60NA  131K  3.6CL  97CALCIUM  7.5CO2  27.0DBILI  <0.1OSMO  263.4ANION GP  10.6BUN/CRE  18.9LDH  4CRP  1.50FERRITIN  325 Jul-10-2022 0445 Serology PROCALC  0.08 Jul-10-2022 0445 Hematology WBC  5.3RBC  2.23HGB  7.1HCT  21.8MCV  97.8MCH  31.8MCHC  32.6RDW  25.3RDWSD  83.5PLT  165MPV  11.7AUTONEU%  72.2AUTOLYM%  13.9AUTOMON%  12.8AUTOEOS%  0.2AUTOBAS%  0.0AUTONEU#  3.8AUTOLYM#  0.7AUTOMON#  0.7AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.1IG#  0.05IG%  0.9 Jul-10-2022 0445 Chemistry GLUCOSE  91BUN  14CREAT  0.9MDRD GFR  60NA  135K  3.4CL  99CALCIUM  7.7CO2  29.6OSMO  270.2ANION GP  9.8BUN/CRE  15.6CRP  1.30MAGNESIU  2.5TROPI-HS  200 Jul-09-2022 2030 Chemistry TROPI-HS  554MAGNESIU  1.5 Jul-09-2022 1730 Chemistry TROPI-HS  708 Jul-09-2022 1616 Urinalysis Department SPECGRAV  1.020U-PH  6.0LEUCOCYT  ModerateNITRITES  PositivePROTEIN  100GLUCOSE  NegativeKETONES  NegativeUROBILIN  2.0BILRUBIN  NegativeBLOOD  LargeCOLOR  Lt. YellowCLARITY  Sl CloudyMICROSCP  YCULTURE  YWBC  10-15RBC  0-2SQUAM EP  0-2BACTERIA  1+MUCUS  None Jul-09-2022 1616 Microbiology C UR  Escherichia coli Jul-09-2022 1520 Serology PROCALC  0.07 Jul-09-2022 1520 Hematology WBC  8.9RBC  2.53HGB  8.1HCT  24.8MCV  98.0MCH  32.0MCHC  32.7RDW  25.6RDWSD  86.3PLT  201MPV  10.7AUTONEU%  77.6AUTOLYM%  8.4AUTOMON%  13.2AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  6.9AUTOLYM#  0.7AUTOMON#  1.2AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.1RET#  0.20RETIC  8.11IG#  0.06IG%  0.7 Jul-09-2022 1520 Chemistry GLUCOSE  103BUN  12CREAT  1.0MDRD GFR  53NA  132K  2.9CL  96CALCIUM  7.8ALK PHOS  55CO2  29.6AST  146ALT  27AST/ALT  5.4TL PROT  8.4ALBUMIN  2.7TBILI  1.9OSMO  264.5ANION GP  9.3BUN/CRE  12.0VIT B12  >2000CRP  0.80FERRITIN  117FOL  >20.0IRON  37LACTATE  1.10PROBNP  31088TIBC  214% SAT  17TROPI-HS  716CRP  0.80 Jul-09-2022 1500 Serology COVID  PosINFLUA  NegINFLUB  Neg Imaging Results Chest x-ray shows prior granulomatous disease. Mild pulmonary vascular congestion. No focal consolidation or effusion. Cardiomegaly. Left subclavian dual-chamber pacer. TAVR stent. No acute fracture. Suspected volume overload  Echocardiogram from this morning shows normal left ventricular ejection fraction. Moderate left ventricular hypertrophy. grade 3 diastolic dysfunction. Mild mitral regurgitation. Mild mitral stenosis. Pacemaker present in the right heart. Mild to moderate tricuspid regurgitation P moderate aortic valve regurgitation.  Chest x-ray shows questionable small pleural effusions. Slightly ill-defined opacity in the left upper lung, possibly infiltrate. Slightly prominent her her lower markings slightly decreased, slight pulmonary edema.  Stable cardiomegaly. Blunted left costophrenic angle. Right lung clear. Prominent costochondral calcifications. Calcified granuloma at the periphery of the right upper lobe. Calcified plaque thoracic aorta.  Left subclavian cardiac pacer, unchanged. Changes of transaortic valve replacement.  IMPRESSION: 1. Small left pleural effusion with associated atelectasis and or possibly consolidation. Consider frontal and lateral views of the chest when the patient status permits for further evaluation. 2. Stable cardiomegaly. 3. Prior granulomatous disease.  Social History tobacco use Never Smoked, Smoking Cessation Not Applicable  alcohol use No Known Use  drug use No Known Use  marital status Widowed  sexual behavior Identifies as Female, Does not know sexual orientation, not currently sexually active  occupation Retired  Health Concerns Urinary tract infectious disease  High troponin I level  Essential hypertension  Anemia  Replacement of aortic valve  Acute COVID-19  Father Deceased Heart disease  Mother Deceased Diabetes mellitus  Brother Alive Diabetes mellitus; Kidney disease; Heart disease  Vital Signs Jul-14-2022 2200 T 98.2 HR 70 RR 18 BP   127 /     46  O2Sat 100 Jul-14-2022 2045 HR 77 RR 18 BP   133 /     47  O2Sat 92 Jul-14-2022 2035 T 99.3 PHYSICAL EXAM Constitutional: Patient appears stated age and is in no acute distress at this time.  Cardiovascular: Regular rate and rhythm without gallop or rub. Aortic murmur present. Mild nonpitting edema present in the lower extremities bilaterally. Radial pulses intact 2+ bilaterally.  Respiratory: Coarse lung sounds bilaterally. Upper airway sounds present. No accessory muscle use, no respiratory distress. Patient is currently on room air.  Gastrointestinal: Abdomen soft, no abdominal tenderness. No rebound or guarding. No distension. No ascites. No organomegaly.  Psychiatric: Patient responds appropriately to questions and displays normal affect. Appears to have good judgment.  Consultations Cardiology  Hospital Course an 81 year old female presenting to the hospital due to cough that is not resolving. She was found to be COVID positive and to be having an acute exacerbation of heart failure. Her past medical history is significant for essential hypertension, hyperlipidemia, and nephrolithiasis. She was diuresed and closely monitored for her respiratory status. Her cough improved as did her lower extremity edema that was severe on admission. During her stay she had a stress test that did not reveal any ischemia. She underwent a TEE for evaluation of her aortic valve that had a previous TAVR. Her lisinopril and Coreg were both increased by cardiology and the patient tolerated these changes in medication. During her stay the patient was found to become hypoxic at night requiring a Noc Ox study which found her to need 2L supplemental oxygen at night. On hospital day 5 the patient's anemia worsened to the point that she needed a transfusion. She was found to have antibodies requiring further evaluation in order to find blood that was compatible for her. Her hemoglobin improved appropriately following transfusion and she was deemed stable for discharge.  Condition at Discharge Stable  Discharge Medications amLODIPine Besylate Oral Tablet 10 MG 10 MG ORALLY AT BEDTIME Aspirin Adult Low Dose Oral Tablet Delayed Release 81 MG 81 MG ORALLY ONCE A DAY Atorvastatin Calcium Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY B Complex Oral Capsule 1 TAB ORALLY ONCE A DAY CARVEDILOL 6.25 MG ORALLY TWICE DAILY BLOOD PRESSURE MEDS (ePrescribed by (name withheld) on Jul-15-2022 1545) Cephalexin Oral Tablet 500 MG 500 MG ORALLY EVERY 12 HOURS (ePrescribed by (name withheld) on Jul-15-2022 1545) Enalapril Maleate Oral Tablet 10 MG 10 MG ORALLY TWICE DAILY Lasix Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY Pantoprazole Sodium Oral Tablet Delayed Release 40 MG 40 MG ORALLY ONCE A DAY (ePrescribed by (name withheld) on Jul-15-2022 1545) Potassium Chloride Crys ER Oral Tablet Extended Release 10 MEQ 1 TAB ORALLY ONCE A DAY Vitamin D (Cholecalciferol) Oral Capsule 50 MCG (2000 UT) 1 TAB ORALLY ONCE A DAY Discharge Disposition Discharge to home  Plan Assessments: - Acute exacerbation of chronic diastolic grade 3 heart failure, improving - COVID-19 infection - Nocturnal hypoxia - Urinary tract infection secondary to E. coli - Hypertension, unknown control - Hyperlipidemia - Nephrolithiasis - Aortic stenosis status post TAVR - Iron deficiency anemia, worsening - CKD stage 3A, stable - Pacemaker in situ - Degenerative arthritis - MDS - Hyponatremia - Hypokalemia, resolved  Plan: - Patient will need follow up for EGD/colonoscopy. Per review of Dr.'s documentation in 2016, the patient was to have follow up endoscopy in 5 years. She had a positive FOBT and needs evaluation. She would like to hold of scheduling this for now. - Coreg increased to 6.25 mg BID. - Continue 40 mg pantoprazole daily. - Continue Cephalexin BID for one day to complete treatment of urinary tract infection. - Repeat CBC in 1 week to evaluate anemia. - Follow up with Oncologist is scheduled for the end of this month. - Follow up with PCP in 5-7 days. - Follow up with Dr. in 2 weeks. - Follow up with dermatology outpatient. - Continue 2L supplemental oxygen at night.