Date of Admission: 10/11/2023   Date of Discharge: 10/13/2023   Issues to be Addressed at Follow-up: + follow up with dementia. Sent home with trazodone for sleep + follow up anemia. econsult to GI for outpatient colonoscopy was done. May resume pradaxa in 5 days if no bleeding + medications review, adjustment: lasix, losartan were held and metop was reduced in the setting of GIB & anemia. Please resume if needed         Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 9/13/2023 to 10/14/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) GI HEMORRHAGE   ? COVID-19 DISEASE   ? HX OF FALL   ? TRICUSPID VALVE REGURGITATION   ? MILD VASCULAR NEUROCOGNITIVE DISORDER WO BEHAVIORAL DISTURBANCE   ? HX OF EMBOLIC STROKE       EMBOLIC STROKE [I63.40] » HX OF EMBOLIC STROKE [Z86.73]   Favor embolic stroke.     ? CHF (CONGESTIVE HEART FAILURE), UNSPECIFIED       2/27/2023  Stable - statin, lasix,       Summary3/7/17 echo  Normal left ventricular size and systolic function with an estimated  ejection fraction of 65-70%.  Moderate mitral regurgitation.  The aortic valve is trileaflet.  Aortic sclerosis present w/o stenosis  Mild aortic insufficiency.  Moderate tricuspid regurgitation.  The IVC is moderately dilated with partial inspiratory collapse suggestive  of a Cvp of 15-20 mmhg.  The estimated pulmonary systolic pressure is 41 mmHg plus the right atrial  pressure.  Moderate left atrial enlargement.  Severe right atrial enlargement.  Normal right ventricular size and function.  No pericardial effusion is present.   By comparison to that study done 21616, the estimated PSP and CVP are  increased.   ? ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE       2/27/2023  Pradaxa, metorpolol   ? HYPERLIPIDEMIA       2/27/2023  statin    ? HTN (HYPERTENSION)       2/27/2023     BP Readings from Last 3 Encounters: 02/27/23 136/64 09/13/22 136/89 02/28/22 136/61   Cozaar, metoprolol       Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Background 80 Y female with past medical history significant for AFib on Pradaxa, hx of ischemic CVA, hx of hysterectomy, Hypertension, hyperlipidemia, Tricuspid regurgitation and mitral regurgitation, hx of CHF, and mild vascular neurocognitive d/o without behavioral disturbance who presented with black stools x couple days with some bright blood. Also with freq falls at home ( 4 the past moths/ year), last one was a week ago when she fell asleep on the couch and fell forward onto the floor, hitting the left temple area.     Subjective: Husband at bedside   Patient still confused but better than yesterday. She denied having shortness of breath/ chest pain / abdominal pain/ nausea/vomitting .    She was able to tell that she's in home town. Recognized her husband and knew that they've been married for 60 years . Patient was able to ambulate to the bathroom by herself with standby assist, able to brush her teeth, wash her face, got back to bed without any issue Per husband, patient hasn't been sleeping at home. She usually woke up, try to  organize the house, then re-organize it because she forgot she already did it. Then she takes nap during the day. Occasionally talking to someone who wasn't there    BP 140/63  | Pulse 88  | Temp 98.2 °F (36.8 °C)  | Resp 16  | Ht 1.626 m (5' 4")  | Wt 49.9 kg (110 lb 0.2 oz)  | SpO2 100%  | Breastfeeding No  | BMI 18.88 kg/m²    Physical Exam: General appearance - alert  , in no acute distress   Mental Status - alert, oriented x self, person,  Knew where she was, able to answer questions appropriately, followed simple commands  Chest -   clear to ascultation bilateral  Heart - regular   rate and rhythm  Abdomen - soft, nontender  , non distended  Neurological - motor and sensory   grossly normal bilaterally  Extremities - no clubbing, cyanosis   Skin - warm and dry       EGD INDICATION/PREOP DX: 1. Dark stools and anemia.  2. H/o pradaxa with supratherapeutic INR.  3. Incidentally covid+.   POSTOP DX: 1. Normal EGD, no old blood or bleeding seen.        Assessment and Plan:   Patient Active Hospital Problem List:  GI HEMORRHAGE (10/11/2023) - suspect UGIB. On pradaxa, no NSAID, s/p Praxbine and vit K - baseline Hb ~ 12, down to 8.6 on admission.   - vitals overall ok. Hb overall stable around 7.5ish - discussed with dr. from GI, patient is ok to go home and resume pradaxa in 5 days and outpatient colonoscopy from GI standpoint - plans:  +  Continue reduced metop, continue to hold lasix & losartan for now + resume pradaxa in 5 days if no more bleeding + ppi daily + patient to follow up with PCP as outpatient, resume medications as able  +   econsult to GI for colonoscopy done     HX OF FALL (10/11/2023) - freq falls, last one was a week ago when she fell while sleeping on yhe sofa and the falls.  - seen by PT , recommended home health        POSITIVE COVID TEST - patient reported feeling tired one week ago. no fever or chills, or cough or HA. She is asymptomatic at this time.  - discussed with ID, given this is a new dx, will need 10 days on isolation       HTN (HYPERTENSION) (3/22/1995) - BP overall acceptable Plan + hold lasix, losartan. Continue reduced metop in the setting of anemia. Patient to follow up with PCP for further medications adjustment        ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE (6/7/2011) - rate controlled currently - metop was reduced in the setting of UGIB - plan: continue lower dose of metop, hold pradaxa for 5 days and resume if no bleeding by then.       CHF (CONGESTIVE HEART FAILURE), UNSPECIFIED (6/8/2014) - currently euvolemic - Plan: continue to hold lasix for now due to acute anemia. Patient to follow up with PCP       HX OF EMBOLIC STROKE (4/12/2017)  HYPERLIPIDEMIA (6/10/2010) - at baseline, non-focal - Plan: continue statin, continue to hold Pradaxa as mentioned above       MILD VASCULAR NEUROCOGNITIVE DISORDER WO BEHAVIORAL DISTURBANCE (4/3/2023) - Spouse states that the pt occasionally talks about hearing people outside when they are not there. Also no sleeping at night.  ? Dementia with hallucination - seen by psych, no melatonin due to side effect in the past - patient seems somewhat confused but still responsive and appropriate - plans: patient can go home since she would do better in her home enviroment. Trazodone qhs for sleep.   Follow up with PCP       l      husband was updated. All questions were answered and he agreed with the above plans         Primary Procedures:          Complications: none   Consults:  GASTROENTEROLOGY - INITIAL INPATIENT CONSULTATION. GASTROENTEROLOGY - ONGOING INPATIENT CONSULTATION.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author  (D.O.) File Time 10/13/2023  1:38 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor  (D.O.) Specialty Hospital Medicine Hospital Acct # Admit Date 10/11/2023  ED to Hosp-Admission (Discharged) on 10/11/2023  ED to Hosp-Admission (Discharged) on 10/11/2023   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   Hospital Problem List   HTN (HYPERTENSION)  HYPERLIPIDEMIA  ATRIAL FIBRILLATION, UNSPECIFIED W PROTHROMBOTIC STATE  CHF (CONGESTIVE HEART FAILURE), UNSPECIFIED  MILD VASCULAR NEUROCOGNITIVE DISORDER WO BEHAVIORAL DISTURBANCE  HX OF EMBOLIC STROKE  TRICUSPID VALVE REGURGITATION  GI HEMORRHAGE  COVID-19 DISEASE  HX OF FALL Care Timeline  10/11   Admitted from ED (Observation) 1748 10/13   Discharged 1700  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 10/13/2023) Medication List at Discharge   dabigatran etexilate mesylate 150 mg Take 1 capsule by mouth 2 times a day HOLD FOR 5 DAYS. IF NO SIGN OF BLEEDING AFTER 5 DAYS ( no black/ bloody stool), may resume this medication. take with a full glass of water. Do not break, chew, or open capsule  fluticasone propionate 50 mcg/actuation 2 Sprays Each nostril DAILY  lovastatin 20 mg Take 1 tablet by mouth daily with the evening meal for cholesterol  metoprolol tartrate 50 mg Oral 2 TIMES A DAY WITH MEALS  pantoprazole sodium 20 mg Oral 2 TIMES A DAY  trazodone HCl 50 mg Oral EVERY BEDTIME AS NEEDED