Date of Admission:  10/17/2023   Date of Discharge: 11/2/ 2023   Issues to be Addressed at Follow-up: 1. Streptococcus pneumoniae bacteremia : completed 14 days of iv antibiotic today 11/1/2023 2. Dense atelectasis vs abscess in right Lower lung and atelectasis in left lower lung : 2 more weeks of Augmentin and CXR in 4 weeks , needs pulm toileting with aerobika  3. Covid 19 pneumonia : symptom onset, day 0 10/11/23 off isolation on 11/1/2023 4: acute hypoxemic respiratory failure : improved, no need for oxygen at rest, needs 2 L on exertion, PT and activity  5 diarrhea: c diff negative all stool studies negative so far, improved  6. AIDS : long standing on Triumeq  7. New Atrial Fibrillation  : on amiodarone, pradaxa , needs follow up with Dr  8. debility : due to acute illness, needs daily PT /OT  Labs CBC , chem-7 weekly while at SNF . TSH in 4 weeks while on amiodarone  Radiology ; CXR  in 4 weeks  Appointments : needs follow up with PCP in 3-5 days of Dc from SNF , appointment with cardiology in 4-6 weeks      Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   10/24/2023  4:43 PM RESPIRATORY CULTURE In process SPUTUM         Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA       De-isolated 11/1/2023   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? CAD WO ANGINA, PRESENCE OF STENT       Cardiac Catheterization 8/24/2016: Right dominant.  LMCA: Normal.  LAD: 90% mid LAD treated with Synergy 3.0 x 20 mm DES jailing two small diagonals  LCx: Normal.  RCA: Normal.Dominant vessel   ? AIDS (ACQUIRED IMMUNE DEFICIENCY SYNDROME)   ? ATRIAL FIBRILLATION, PAROXYSMAL       10/20/2023 while hospitalized with COVID pneumonia   ? HYPONATREMIA   ? ASTHMA, UNSPECIFIED     Resolved Hospital Problems   Diagnosis Date Resolved ? GRAM POS BACTEREMIA 11/01/2023 ? ACUTE RENAL FAILURE, UNSPECIFIED 10/22/2023     Discharge Disposition:  Skilled Nursing Facility   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course with Narrative: 74 years old male with history of chronic HIV infection on Triumeq, never vaccinated against COVID-19, asthma, COVID-positive on 10/14/2023 presented to ED with bilateral pneumonia.  Admitted 10/18/2023 with severe respiratory failure requiring high flow oxygen.  Admitted to ICU   with steroid, remdesivir, antibiotic.  Blood cultures 2 out of 2 returned positive for Streptococcus pneumonia. Complicated by A-fib with RVR treated with amiodarone. Eventually high flow oxygen was weaned off and downgraded to med telemetry on 10/22/2023. Worsening oxygen requirement on 10/23/2022 from 2 L of oxygen to high flow oxygen. CT angiogram done was negative for pulmonary embolus.  However did show right lower lobe abscess versus atelectasis .  Antibiotics were broadened.  Pulmonary medicine consulted and antibiotic narrowed eventually to Unasyn.  Sputum culture sent off negative , B-type D glucan and aspergillus galactomannan in sputum negative  Hospital stay complicated by  severe diarrhea, C. difficile negative stool bacterial pathogen assay negative.  Imodium and Pepto-Bismol started with improvement in diarrhea.rectal tube discontinued this am  Antibiotic coverage narrowed to ceftriaxone and Flagyl 10/26/2023 Assumed care on hospital day 14 Doing well, tapered off oxygen . Saturating 94-95% RA ,   Repeat Ct chest still showed dense atelectasis at B/L lower lobes and possible some minimal  necrosis in RLL.? Abscess vs atelectasis . Pulmonary on call Dr recommended  Aggressive pulmonary toileting, out of bed activity , Augmentin for 2 more weeks and repeat CXR in 4 weeks . Spot diuresis if needed . FU with PCP .  Given small dose of lasix 10 mg iv X1 this am  Saturation better , no desaturation on room air when out of bed today . Complains of dizziness but BP on sitting stable, HR stable at 70s, no focal neuro deficit . Suspect du eto overall deconditioning . Placed on ted hose for out of bed activity  Pt seen by PT , recommending daily PT . Pt agreeable  Dc to SNF when bed available      Problem List and Treatment Plan: 1.Covid 19 pneumonia /Acute hypoxemic respiratory failure/Asthma  Symptom onset 10/11/2023 , day 0 , d-  isolated 11/1/2023 Completed treatment with remdesivir and steroids Was on high flow oxygen , now off oxygen during rest, sats 93-94%,  2.  Streptococcus pneumoniae bacteremia  2/2 with possible Streptococcus pneumonia along with COVID-19 -Repeat blood cultures negative  TTE 10/25/2023 negative for any vegetations  -completed 2 weeks iv antibiotic  11/1/2023  -sputum cultures negative for PJP, negative  Augmentin X 2 more weeks,  CXr in 4 weeks  3.Diarrhea   C diff negative  Bacterial enteric pathogen negative  O&P in process  Improved on Pepto bismal and imodium , continue   4..AIDS  Long standing , follows with Dr    c/w Triumeq  Lab Results Component Value Date   CD4/100 cells 32 (L) 10/28/2022   CD4 count 621 05/04/2023   CD4/100 cells, qn 37 05/04/2023 5.. Paroxysmal atrial fibrillation  In the setting of severe illness: pneumonia, bacteremia, hypoxic respiratory failure   on amiodarone, iv on 10/18, has been on amiodarone 200 BID since 10/20, tapered to q daily 11/1/2023. HR stable, sinus rhythm so far. In 70s  Discussed with Dr, continue amiodarone, okay to taper to daily dose , recommended anticoagulation and FU as outpatient to see decide  if and when to taper off amiodarone once acute illness stabilized  Discussed risk and benefit of anticoagulation  with patient in detail , agrees with DOAC , started on pradaxa 150 BID on 11/1/2023 TSH in process follow as outpatient  6. CAD s/p PCI in 2016  noted, asymptomatic  C/w  metoprolol low dose , aspirin stopped as starting on pradaxa for Atrial Fibrillation  , discussed with cardiology on call Dr, no need for asa as pt will be on pradaxa  7.. Hyponatremia /AKI  Resolved    SNF Care: 1. Reason for SNF placement: PT  2. Expected SNF goals: per PT  GOALS   Patient will be: 1) independent with bed mobility 2) independent with transfers 3) independent to ambulate 150 feet with least restrictive assistive device 3. Anticipated location of disposition: home with family  4. Condition prior to discharge: vital signs stable, Moderate assist for transfers with front wheeled walker Moderate assist for sidestepping along bed 3 feet with front wheeled walker; minimal to moderate fatigue 5. Home/Social Situation:  Lives with wife in single level home, no steps to enter  6.Prior level of function ( before hospital admission ) Independent and ambulatory without assistive device; independent with activities of daily living   Primary Procedures:  None   Secondary Procedures: None   Complications: none   Code Status at Time of Discharge: full code    PROGRESS NOTE :  S: pt c/o some dizziness, no room spinning , no NV  No chest pain  Able to sit  in chair  Encouraged out of bed activity  C/o diarrhea but only 2 stools yesterday , once last last night na small this am    O  BP 133/61  | Pulse 70  | Temp 98.2 °F (36.8 °C)  | Resp 18  | Ht 5' 8"  | Wt 63.4 kg (139 lb 12.4 oz)  | SpO2 93%  | Breastfeeding No  | BMI 21.25 kg/m²  Chest: decreased BS in B/L bases, few crackles/ronchi at bases posteriorly , no wheezing  Abdomen soft non tender  No leg swelling  No facial asymmetry    globally weak, no focal weakness    LABS REVIEWED, stable          Note Details  Author (M.D.) File Time 11/2/2023 12:41 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 10/17/2023  ED to Hosp-Admission (Discharged) on 10/17/2023  ED to Hosp-Admission (Discharged) on 10/17/2023   Detailed Report  Note shared with patient Hospital Problem List   ASTHMA, UNSPECIFIED  ATRIAL FIBRILLATION, PAROXYSMAL  COVID-19 PNEUMONIA  ACUTE HYPOXEMIC RESPIRATORY FAILURE  HYPONATREMIA  ACUTE RENAL FAILURE, UNSPECIFIED Resolved  GRAM POS BACTEREMIA Resolved  AIDS (ACQUIRED IMMUNE DEFICIENCY SYNDROME)  CAD WO ANGINA, PRESENCE OF STENT Care Timeline  10/17   Admitted to ICT-INTENSIVE CARE NURSE UNIT from ED 1713 10/22   Transferred out of ICT-INTENSIVE CARE NURSE UNIT 1343 11/02   Discharged 1540  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 11/2/2023)   Follow-Ups: Follow up with SNF   Discharge Orders XR CHEST, PA AND LATERAL... PT IS NOT VACCINATED -NOT ON IMMJNIZATION LIST