Date of Admission: 8/17/2023   Date of Discharge: 8/18/2023   Issues to be Addressed at Follow-up: Patient to resume ongoing medical care with MD Remained in COVID precaution isolation until 08/2 7/2023   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   8/18/2023 12:40 AM MRSA SCREENING CULTURE In process NARES       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE ON CHRONIC RESPIRATORY FAILURE       Oxygen ordered on 6/2/2022 and exp 9/2/2030 being used for asthma and ESRD on dialysis   ? SURGICAL ARTERIOVENOUS FISTULA THROMBOSIS   ? LONG TERM ANTICOAGULANT THERAPY   ? HOMOCYSTEINEMIA   ? ANTIPHOSPHOLIPID SYNDROME       Thrombosed aorta in 2003 and required aortomesenteric bypass. Hospitalized for 7 months, open abdomen, trached, ARF leading to HD, transferred to Facility at that time. On lifelong coumadin. + for hyperhomocysteinemia, negative for Factor 5 Leiden, and the prothrombin gene mutation hyperhomocystenemia, and antiphospholipid syndrome.     To lower homocysteine levels, take folic acid (1 mg/day), vitamin B6 (10 mg/day), and vitamin B12 (0.4 mg/day). All patients should receive a B complex vitamin to prevent peripheral neuropathy.These are over the counter supplements.   She is already on coumadin (lifelong) for catastrophic clot of aorta.   ? ESRD ON HEMODIALYSIS       TTS   ? DIASTOLIC HEART FAILURE, CHRONIC   ? ANTICOAGULATION MONITORING, INR 2.0-3.0       Antiphospholipid syndrome   Changed to 2.0-3.0 2/29/20 per hematology   ? HTN   ? HYPOTHYROIDISM   ? HYPERLIPIDEMIA   ? COVID-19 DISEASE   ? HX OF VENOUS THROMBOEMBOLIC DISEASE   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? SECONDARY HYPERPARATHYROIDISM, RENAL ORIGIN     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 79-year-old woman with history of antiphospholipid antibody syndrome, homocystinemia, on long-term anticoagulation, history of heart failure with preserved EF, ESRD on hemodialysis (TTS) with previous AV fistula thrombosis, HTN, hypothyroidism, hyperlipidemia, and chronic hypoxemic respiratory failure secondary to COPD on 4-5 L around-the-clock, who presented to ED on 08/1 7 secondary to shortness of breath of 3 days duration with associated moist cough.  She did not have fever.  While at the hemodialysis center she became short of breath because her oxygen tank had run out.  In the ED her oxygen saturation was 100% 4 L on nasal cannula with respiratory rate of about 22 and she was positive for COVID.  She was started on remdesivir.  Overnight she remained afebrile, O2 requirement was down to 2 L/min with 99 to 100% saturation.  Respiratory rate was starting to 20.  Although initially in the ED she had a respiratory rate up to 28.    Active Hospital Problems   Diagnosis   ? (Principal) ACUTE ON CHRONIC RESPIRATORY FAILURE       --Acute shortness of breath precipitated alcohol due to patient running out of oxygen while at dialysis center.  She was essentially on room air whereas at baseline she was on 4 to 5 L.  Once supplemental oxygen has been placed her oxygenation was back to baseline.  Preliminary review of chest x-ray revealed no acute infiltrate.  She is not febrile and no other indications of acute infection.  Her COVID test therefore appeared to be incidental and not precipitant of her respiratory status. ----Oxygen supply situation has been remedied.  Confirmed that she will have ample amount of oxygen supply at home and will be taking them to dialysis center on her dialysis days.    COVID-19 DISEASE --- Without clinical evidence of infections.  In addition to being fully immunized against COVID, she has had a COVID infection in 2022.  Current infection has no symptoms and no associated SOB. --- No indication for continuation of antiviral medication or even institution of steroid. --- Precautions/isolation to end on 08/27   ?     ? LONG TERM ANTICOAGULANT THERAPY   ? HOMOCYSTEINEMIA   ? ANTIPHOSPHOLIPID SYNDROME       --- Continue Coumadin as before   ? ESRD ON HEMODIALYSIS       TTS --- Continue   ? DIASTOLIC HEART FAILURE, CHRONIC --- Stable     ?           ? HTN -- Controlled     ? HYPOTHYROIDISM --- Continue levothyroxine     ? HYPERLIPIDEMIA   ?     ?     ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? SECONDARY HYPERPARATHYROIDISM, RENAL ORIGIN --- Continue outpatient treatment       Primary Procedures:      Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Shortness of breath secondary to running out of oxygen   Complications: none   Consults:  None Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author (M.D.) File Time 8/18/2023 10:50 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 8/17/2023  ED to Hosp-Admission (Discharged) on 8/17/2023  ED to Hosp-Admission (Discharged) on 8/17/2023   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   SECONDARY HYPERPARATHYROIDISM, RENAL ORIGIN  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  ACUTE ON CHRONIC RESPIRATORY FAILURE  HX OF VENOUS THROMBOEMBOLIC DISEASE  COVID-19 DISEASE  SURGICAL ARTERIOVENOUS FISTULA THROMBOSIS  ANTIPHOSPHOLIPID SYNDROME  HOMOCYSTEINEMIA  LONG TERM ANTICOAGULANT THERAPY  HTN  DIASTOLIC HEART FAILURE, CHRONIC  ESRD ON HEMODIALYSIS  ANTICOAGULATION MONITORING, INR 2.0-3.0  HYPOTHYROIDISM  HYPERLIPIDEMIA