Date of Admission: 10/28/2023   Date of Discharge: 11/2/2023   Issues to be Addressed at Follow-up: 1. Continue COVID precautions until 11/06/2023 2. 30 day event monitor ordered to monitor heart rhythm 3. Optimization of BP regimen with PCP 4. Discharged on home O2 to be used at night (2L qhs) 5. Outpatient sleep apnea evaluation per PCP   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/28/2023  7:58 AM CHEM 7 (NA, K, CL, CO2, BUN, GLUC, CR) In process --   10/28/2023  5:28 AM BLOOD CULTURE 2 Preliminary BLOOD   10/28/2023  5:28 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? COVID-19 PNEUMONIA   ? SYNCOPE   ? SCALP HEMATOMA   ? HX OF ISCHEMIC STROKE       ACUTE STROKE DUE TO ISCHEMIA, UNSPECIFIED TYPE AND ARTERY [I63.9] » HX OF ISCHEMIC STROKE [Z86.73]   ? MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMERS DISEASE (ALZHEIMERS DEMENTIA)       1/4/2023 - Chart Update Stable, on medication     ? BILAT OPEN ANGLE GLAUCOMA       1/4/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Stable, using eye drops Following up with ophthalmology.     ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)       1/4/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.  Stable on protonix Advised about diet modification.     ? HTN (HYPERTENSION)       1/4/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.    BP Readings from Last 3 Encounters: 01/04/23 133/77 12/27/22 121/82 10/18/22 148/64   At goal On amlodipine and HCTZ      ? HYPOTHYROIDISM       1/4/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   Lab Results Component Value Date   TSH 4.6 03/04/2021   At goal, will recheck  Continue levothyroxine       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   History of Present Illness per Dr.: Patient 90yo F with Alzheimers and history of CVA and CAD was found down by caretaker in home when she was apparently trying to walk to the bathroom and presumed to have a syncopal episode. On presentation she was found to have mild hypoxemia (2L NC requirement to maintain SpO2 >94%) from COVID. She reports feeling totally fine lately, without any F/Ch/N/V/D/C/Dyspnea/pain or other concerns.   Hospital Course and Significant Findings: Patient admitted on 10/28/23 with syncope and acute hypoxemic respiratory failure 2/2 to COVID pneumonia. She was started on remdesivir and decadron. Home antihypertensive hydrochlorothiazide was held due to mild hyponatremia which seems at baseline (132). Given unclear etiology of syncope and fall, she was evaluated with CT head (negative), ECHO (grade 1 diastolic dysfunction) and telemetry monitoring. She was noted to have brief episodes of NSVT and was started on metoprolol. A 30 day event monitor was approved by cardiology for further home monitoring. Home antihypertensive amlodipine was stopped and lisinopril was started for improved BP control. She required oxygen intermittently especially for nocturnal desaturation which could be in the setting of undiagnosed sleep apnea. Patient is discharged on home O2 (2L qhs). Currently stable for discharge with 30 day event monitor and close PCP follow up.    Physical Exam:   Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 (LPM) O2 Delivery 11/02/23 1256 97.9 °F (36.6 °C) Oral 55 124/68 16 93 % 2 LPM NC 11/02/23 0820 97.4 °F (36.3 °C) Oral 63 147/53 16 93 % 2 LPM NC 11/02/23 0500 97.6 °F (36.4 °C) Oral 54 148/59 18 97 % 2 LPM NC 11/02/23 0100 ? ? ? ? ? ? 2 LPM NC 11/01/23 2346 97.7 °F (36.5 °C) Oral 58 153/66 17 91 % ? RA 11/01/23 1915 97.4 °F (36.3 °C) Oral 75 151/61 18 96 % ? RA 11/01/23 1730 ? ? 74 152/87 ? ? ? ? 11/01/23 1559 97.6 °F (36.4 °C) Oral 61 150/74 ? 97 % ? RA     General appearance - well looking, no distress HEENT- peri-ocular ecchymosis bilaterally L >R Chest - clear to auscultation, no wheezes, rales or rhonchi  Heart - regular rate and rhythm  Abdomen - soft, nontender, nondistended, no masses or organomegaly  Extremities - no clubbing, cyanosis or edema    Syncope Fall Peri-ocular ecchymosis Scalp Hematoma   - has LBB which is chronic/unchanged  - wore event monitor 2021 post stroke, sinus, no afibb or arrhythmia - suspect possible orthostasis - was taking HCTZ, hypoNa - occurred from seated to standing position (went to bathroom and returning to bed)  - possible, but lower suspicion for hypoxemia from COVID as cause - tele monitoring - event monitor on discharge, approved by Cardiology Dr. 10/31/23  - s/p echo 10/30/23  - pt eval   Non Sustained Ventricular Tachycardia  - mild episodes noted on telemetry without symptoms and non-sustained - event monitor on dc  - tele monitoring - metoprolol 25 mg PO BID    Acute Hypoxemic Respiratory Failure  COVID 19 Pneumonia  Sepsis  - age adjusted D-dimer, suggestive against PE/VTE - blood cultures in process - prelim negative - completed RDV day 5/5 - completed decadron day 5 - minimal oxygen requirements, mainly at night - home oxygen at time of discharge for 2L qhs - PCP follow up for sleep apnea evaluation - monitor    Hx of Stroke - atorvastatin  - plavix    Diastolic Heart Failure Aortic Regurgitation  Tricuspid Regurgitation  - grade 1 diastolic dysfunction   - no signs of vol OL on exam - repeat ECHO 10/30/23 - surveillance ECHO per PCP    Dysphagia?  - daughter voices some concerns regarding patient's ability to swallow - no obvious deficits noted during admission - SLP eval obtained - normal  CAD Demand Ischemia   - no chest pain - EKG similar to prior do not suspect ACS - plavix - statin    Alzheimer's Dementia  - noted - appears to be otherwise very alert and relatively high functioning - continue donepezil    Glaucoma  - continue eye gtt    GERD  - asymptomatic - ppi    Hypothyroidism - levothyroxine     Hypertension - was on hctz prior to admission - held due to hypoNa - started amlodipine 5 mg PO QD 10/29/23 - increased to 7.5 mg PO QD 10/30/23 - will d/c all together in favor of metoprolol - metoprolol 25 mg PO BID - monitor  - added lisinopril 2.5 mg daily - BP medication optimization outpatient   Hyponatremia  - improving and stable  - hctz held  - monitor      Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Syncope, COVID 19   Complications: none   Consults:  None Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR       Note Details  Author (M.D.) File Time 11/2/2023  2:47 PM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine Admit Date 10/28/2023  ED to Hosp-Admission (Discharged) on 10/28/2023  ED to Hosp-Admission (Discharged) on 10/28/2023   Revision History   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   HYPOTHYROIDISM  HTN (HYPERTENSION)  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  BILAT OPEN ANGLE GLAUCOMA  MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMERS DISEASE (ALZHEIMERS DEMENTIA)  ACUTE HYPOXEMIC RESPIRATORY FAILURE  HX OF ISCHEMIC STROKE  COVID-19 PNEUMONIA  SYNCOPE  SCALP HEMATOMA Care Timeline  10/28   Admitted from ED (Observation) 0838 10/31   Admitted 1347 11/02   Discharged 1420  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 11/2/2023)   Discharge Orders  30 DAY EVENT MONITOR, CV Medication List at Discharge   amitriptyline HCl 100 mg Take 1 tablet by mouth daily at bedtime. Do not convert. (Note: dosage change)  atorvastatin calcium 40 mg Oral DAILY  clopidogrel bisulfate 75 mg Oral DAILY  donepezil HCl 10 mg Oral DAILY  fluocinonide 0.05 % Apply to affected area(s) 2 times a day as needed for rash . Stop when rash is gone. Do not use on face, neck or skin folds  levobunolol HCl 0.5 % 1 Drop Both eyes 2 TIMES A DAY  levothyroxine sodium 50 mcg Oral DAILY  lisinopril 2.5 mg Oral DAILY  metoprolol tartrate 25 mg Oral 2 TIMES A DAY  pantoprazole sodium 40 mg Oral 2 TIMES A DAY BEFORE MEALS  trazodone HCl 50 mg Take one-half tablet by mouth at bedtime only as needed for sleep. After 1 week, may increase to 1 tablet at bedtime only as needed for sleep  triamcinolone acetonide 0.1 % Apply to affected area(s) 2 times a day as needed for rash . Stop when rash is gone. Do not use on face, neck or skin folds