Date of Service Jul-20-2022 0624  Date of Admission Admit Date: Jul-13-2022  Date of Discharge Date of discharge Jul-20-2022  Allergies Codeine - Shock  Chief Complaint Shortness of breath  Final Diagnoses Acute renal failure syndrome  resolved  Acute on chronic hypoxemic respiratory failure Resolved Jul-20-2022  Pneumonia caused by SARS-CoV-2 Resolved Jul-20-2022  Difficult venous access Resolved Jul-20-2022  Procedure(s) Performed None  Lab Results Jul-20-2022 0528 Point Of Care   Jul-20-2022 0510 Hematology WBC  11.0RBC  4.46HGB  10.6HCT  33.7MCV  75.6MCH  23.8MCHC  31.5RDW  18.0RDWSD  48.0PLT  202MPV  TnpAUTONEU%  82.7AUTOLYM%  7.2AUTOMON%  8.5AUTOEOS%  0.2AUTOBAS%  0.1AUTONEU#  9.1AUTOLYM#  0.8AUTOMON#  0.9AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.14IG%  1.3 Jul-20-2022 0510 Chemistry GLUCOSE  142BUN  59CREAT  2.3MDRD GFR  28NA  135K  4.2CL  102CALCIUM  8.5ALK PHOS  60CO2  26.0AST  8ALT  13AST/ALT  0.6TL PROT  5.8ALBUMIN  2.7TBILI  0.4OSMO  289.1ANION GP  11.2BUN/CRE  25.7 Jul-19-2022 1951 Point Of Care  Jul-19-2022 1659 Point Of Care  Jul-19-2022 1207 Point Of Care  Jul-19-2022 0440 Hematology WBC  11.5RBC  4.40HGB  10.5HCT  34.0MCV  77.3MCH  23.9MCHC  30.9RDW  17.9RDWSD  49.6PLT  206MPV  TnpAUTONEU%  83.2AUTOLYM%  7.6AUTOMON%  8.2AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  9.6AUTOLYM#  0.9AUTOMON#  0.9AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.10IG%  0.9 Jul-19-2022 0440 Chemistry GLUCOSE  147BUN  57CREAT  2.4MDRD GFR  27NA  135K  3.8CL  102CALCIUM  8.2CO2  24.2OSMO  288.6ANION GP  12.6BUN/CRE  23.8TRIG  29CHOL  87LDL CALC  41HDL CHOL  40REL RISK  2.2LDL/HDLD  1.03 Jul-18-2022 0520 Serology PROCALC  <0.05 Jul-18-2022 0520 Hematology WBC  10.6RBC  4.38HGB  10.6HCT  33.6MCV  76.7MCH  24.2MCHC  31.5RDW  18.0RDWSD  49.1PLT  200MPV  TnpAUTONEU%  85.1AUTOLYM%  6.6AUTOMON%  7.3AUTOEOS%  0.1AUTOBAS%  0.1AUTONEU#  9.0AUTOLYM#  0.7AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.09IG%  0.8 Jul-18-2022 0520 Chemistry GLUCOSE  231BUN  53CREAT  2.5MDRD GFR  26NA  134K  4.4CL  101CALCIUM  7.8ALK PHOS  63CO2  24.5AST  15ALT  10AST/ALT  1.5TL PROT  5.8ALBUMIN  2.3TBILI  0.3DBILI  0.1OSMO  290.0ANION GP  12.9BUN/CRE  21.2VANCOMYC  18.8CRP  1.30PK/TR  Random Jul-17-2022 0730 Serology PROCALC  0.06 Jul-17-2022 0730 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Jul-17-2022 0730 Chemistry GLUCOSE  313BUN  50CREAT  2.7MDRD GFR  24NA  136K  3.6CL  101CALCIUM  7.7ALK PHOS  72CO2  24.8AST  9ALT  13AST/ALT  0.7TL PROT  5.7ALBUMIN  2.4TBILI  0.3DBILI  0.2OSMO  297.2ANION GP  13.8BUN/CRE  18.5CRP  1.90 Jul-16-2022 0525 Serology PROCALC  0.08 Jul-16-2022 0525 Hematology WBC  12.2RBC  4.68HGB  11.1HCT  35.9MCV  76.7MCH  23.7MCHC  30.9RDW  18.7RDWSD  48.9PLT  256MPV  11.5AUTONEU%  89.9AUTOLYM%  5.0AUTOMON%  4.4AUTOEOS%  0.1AUTOBAS%  0.1AUTONEU#  11.0AUTOLYM#  0.6AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.06IG%  0.5 Jul-16-2022 0525 Coagulation D-DIMER  0.64 Jul-16-2022 0525 Chemistry GLUCOSE  333BUN  41CREAT  2.8MDRD GFR  23NA  135K  3.5CL  100CALCIUM  7.7ALK PHOS  79CO2  25.0AST  15ALT  13AST/ALT  1.2TL PROT  6.0ALBUMIN  2.1TBILI  0.3OSMO  293.2ANION GP  13.5BUN/CRE  14.6CRP  3.00 Jul-15-2022 0506 Serology PROCALC  0.10 Jul-15-2022 0506 Hematology WBC  14.9RBC  4.56HGB  10.9HCT  35.1MCV  77.0MCH  23.9MCHC  31.1RDW  18.4RDWSD  48.4PLT  267MPV  TnpAUTONEU%  91.1AUTOLYM%  4.0AUTOMON%  4.0AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  13.6AUTOLYM#  0.6AUTOMON#  0.6AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.12IG%  0.8 Jul-15-2022 0506 Chemistry GLUCOSE  331BUN  35CREAT  2.5MDRD GFR  26NA  137K  3.0CL  102CALCIUM  7.7ALK PHOS  78CO2  24.9AST  14ALT  7AST/ALT  2.0TL PROT  5.7ALBUMIN  1.9TBILI  0.4OSMO  294.7ANION GP  13.1BUN/CRE  14.0CRP  4.20 Jul-13-2022 2114 Blood Gas PH  7.37PC02  36.1PO2 ART  70BICARB  20.5BE  -3.6CO2 CT  18.4O2 SAT  92.7O2 THER  50TYPEABG  Arterial Jul-13-2022 1630 Serology PROCALC  0.07 Jul-13-2022 1630 Hematology WBC  12.6RBC  5.74HGB  13.7HCT  44.2MCV  77.0MCH  23.9MCHC  31.0RDW  19.3RDWSD  48.4PLT  375MPV  11.5AUTONEU%  81.6AUTOLYM%  11.0AUTOMON%  4.5AUTOEOS%  1.7AUTOBAS%  0.6AUTONEU#  10.3AUTOLYM#  1.4AUTOMON#  0.6AUTOBAS#  0.1AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.08IG%  0.6 Jul-13-2022 1630 Coagulation D-DIMER  0.63 Jul-13-2022 1630 Chemistry GLUCOSE  289BUN  25CREAT  2.2MDRD GFR  30NA  139K  3.3CL  101CALCIUM  8.7ALK PHOS  105CO2  25.4AST  24ALT  13AST/ALT  1.8TL PROT  7.0ALBUMIN  2.3TBILI  0.6DBILI  0.3OSMO  292.5ANION GP  15.9BUN/CRE  11.4LDH  441CRP  7.50FERRITIN  130HGBA1C  8.6MEAN GLU  229TROPI-HS  84.6 Imaging Results Echocardiogram 07/20/2022, per official report.   "Conclusions Moderate left ventricular hypertrophy (measuring 1.4 - 1.7 cm). Aortic cusps appear mildly calcified. Trileaflet aortic valve. Moderate tricuspid regurgitation. The estimated Peak RVSP is 64 mmHg. Moderate enlargement of right ventricle. Severe right ventricular hypokinesis with right atrial enlargement. Technically difficult study, Limited views. Pulmonary hypertension with RV and RA enlargement consistant with pulmonary process possibly acute."  Functional Status* Impaired mobility, Activity of daily living - Needs assistance  Mental Status* Normal Cognition  Social History tobacco use Former Smoker, 20 yrs, Smoking Cessation Not Applicable  drug use Heroin, Former during his 20s-30s  marital status Married  occupation history of military service  Health Concerns Difficult venous access  Acute renal failure syndrome  Pneumonia caused by SARS-CoV-2  Acute on chronic hypoxemic respiratory failure  Heroin, Former  Former Smoker, 20 yrs  Father Deceased Hypertensive disorder; Coronary arteriosclerosis; Diabetes mellitus; Congestive heart failure  Mother Deceased Hypertensive disorder; Congestive heart failure  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Jul-20-2022 0409 HR 61 RR 14 BP       152  / 96 O2Sat 100 Jul-19-2022 1957 T 97.8 HR 72 RR 16 BP   145 / 80 O2Sat 97 Jul-19-2022 1547 T 97.8 PHYSICAL EXAM CONSTITUTIONAL: Patient is a chronically ill-appearing 68-year-old male resting supine in bed. No acute distress.  EYES: Orbital fat prolapse still present bilaterally. No scleral icterus or conjunctival injection noted. Patient able to maintain appropriate eye contact during conversation. No ocular discharge noted.  CARDIOVASCULAR: Heart rate remains regular with regular rhythm. Peripheral edema consistent with previous examinations. Radial pulses 2+ bilaterally. Right upper extremity PICC line still in place with clean and dry Tegaderm overlying it. No signs of erythema, discharge noted.  RESPIRATORY: Patient is on BiPAP set at 18/10 and FiO2 of 30%. No accessory muscle use or respiratory distress noted. SpO2 is 100% on FiO2 of 30%. Breath sounds are present and equal in bilateral anterior lung fields that are clear on auscultation this morning.  GASTROINTESTINAL: Abdomen is obese, soft, nontender, and nondistended. Bowel sounds present and normoactive. No rebound or guarding noted on palpation.  GENITOURINARY: Foley catheter in place draining clear yellow urine.  PSYCHIATRIC: Patient is awake and alert and oriented to person, place, time, and somewhat situation. Poor historian and poor medical understanding. Mood and affect remain appropriate.  Consultations None  Hospital Course Patient is a 68-year-old male with past medical history significant for hypothyroidism, hypertension, type 2 diabetes, CAD, nephrolithiasis, and neuropathy. He presented to the emergency department on 06/13/2022 in respiratory distress. He was subsequently found to be COVID positive and admitted under the Internal Medicine service with a diagnosis of acute on chronic hypoxemic respiratory failure secondary to COVID 19 pneumonia. Total hospitalization was 8 days.  During the course of his hospitalization patient was successfully titrated from 15 L high-flow BiPAP back to baseline oxygen requirements and on day of discharge is wearing his home nasal Trilogy mask set at 30% FiO2 noted to be 100%. Hospitalization was also complicated by acute renal insufficiency with creatinine of 2.8 on admission and subsequently improved down to 2.3 on day of discharge with 2.3 L of urine output in the 24 hours prior to discharge. Suspect chronic kidney disease, although baseline creatinine is unknown.  Patient also noted to be positive 2/2 bottles on his blood culture from admission with staphylococcal hominis. Patient received 5 days of vancomycin and will be discharged home with additional 5 days of doxycycline bid.  Condition at Discharge Stable  Discharge Medications Atorvastatin Calcium Oral Tablet 80 MG 80 MG ORALLY ONCE A DAY Carvedilol Oral Tablet 25 MG 50 MG ORALLY TWICE DAILY DEXAMETHASONE 6 MG ORALLY ONCE A DAY (ePrescribed on Jul-20-2022 1332) DOXYCYCLINE MONOHYDRATE 100 MG ORALLY TWICE DAILY (ePrescribed on Jul-20-2022 1345) Insulin Lispro Injection Solution 100 UNIT/ML 25 UNT SUBCUTANEOUSLY BEFORE MEALS Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 60 MG 60 MG ORALLY ONCE A DAY Levothyroxine Sodium Oral Capsule 175 MCG 175 MG ORALLY BEFORE BREAKFAST Losartan Potassium Oral Tablet 100 MG 100 MG ORALLY TWICE DAILY metFORMIN HCl Oral Tablet 1000 MG 1000 MG ORALLY TWICE DAILY MiraLax Mix-In Pax Oral Packet 17 GM 1 PK ORALLY TWICE DAILY for ADVERSE DRUG REACTION (ePrescribed on Jul-20-2022 1332) Nitroglycerin Sublingual Tablet Sublingual 0.4 MG Continue taking same as home traMADol HCl Oral Tablet 50 MG 50 MG ORALLY EVERY 4 HOURS AS NEEDED for MODERATE-SEVERE (PAIN 6-10) Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML 100 UNT SUBCUTANEOUSLY EVERY MORNING Zolpidem Tartrate Oral Tablet 10 MG 10 MG ORALLY DAILY AT BEDTIME Discharge Disposition Discharge to home with home health  Plan Assessment/plan: 1. Acute on chronic hypoxic respiratory failure: Secondary to COVID-19 pneumonia, Resolved Patient back on baseline O2 requirements and maintaining appropriate SpO2.  2. COVID-19 pneumonia: Patient completed 5 days of remdesivir and it has been discontinued.  Today is day 8 of 10 Dexamethasone. Will be discharged home with an additional 2 days of Dexamethasone.   3. Bacteremia with Staph hominis 2 of 2 bottles Today is day 5  of Vancomycin. Repeat blood cultures have not shown any growth over 48 hours.  Will discharge him home on doxycycline 100 mg bid for 5 more days.  Transesophageal echocardiogram performed and did not show signs of cardiac vegetation. Repeat blood cultures negative and patient has remained afebrile. Clinically does not appear to have active bacteremia. For these reasons I have low clinical suspicion of endocarditis.   4. Diabetes:  Will continue home diabetes regimen.   5. Hypertension: Continue home meds  6. Acute renal insufficiency, unknown baseline, improving: Cr 2.3 on morning labs; GFR 28. Plan to remove foley catheter prior to discharge. Repeat BMP ordered for 07/25/2022 to follow renal function. We may be near his baseline renal function. Urine output has improved significantly since admission. Had 2.3 L of urine output yesterday.    7. Dependent edema. Improved.  Chronic comorbidities: -Hypothyroidism -Hypertension -DMII -CAD -Peripheral neuropathy   DO, PGY-3  Discharge Instructions Diet Cardiac/Diabetic  Activity As tolerated. PT/OT Home health ordered  Follow up Appointments Schedule follow-up with outpatient PCP within one week of discharge with repeat CMP prior to evaluate renal status.  Primary Care Provider DO  Electronically signed by RESIDENT on Jul-20-2022 1357 I have seen and physically examined the patient on 7/20/22 and agree with the documentation of Dr. I have also discussed my findings and plan of care with Dr. Any changes and additional information are listed below.  Face to face evaluation performed on day of discharge. Repeat cultures negative, afebrile, no obvious valve vegetations on TTE. Suspect staph bacteremia was skin contaminant but will treat out remainder of course with PO doxycycline. Recommended SNF placement for continued rehabilitation though patient and family opted to DC home with HH despite being unable to receive the DME they requested to help care for him.  Discharge time, greater than 30 minutes Electronically signed by DO DO on Jul-20-2022 1718