Date of Admission  01/06/2022   Date of Discharge  01/28/2022   Reason for Hospitalization   chest pain at facility, recently had mitral valve replacement. treated for bacteremia but didn't complete last 2wks abx. had kidney transplant in 2020, given 324ASA today. on 3-4L at baseline.  Hospital Course   Patient is a 60 year old female PMHx severe mitral and tricuspid valve stenosis (s/p 23 mm mechanical mitral valve replacement and tricuspid valvuloplasty with ring 12/10/2021), cardioembolic infarcts with residual L upper extremity and lower extremity weakness (12/2021), ESRD 2/2 membranous nephropathy (s/p deceased donor kidney transplant 3/2020), HTN, DM, HLD, non-obstructive CAD (Cardiac cath 12/2021), moderate pulmonary hypertension, PAD who presented from Facility for chest pain. She was recently admitted to Facility for planned MVR on 12/20/2021 but had incidental finding of severe tricuspid stenosis that was also repaired. Course complicated by paroxysmal atrial fibrillation, cardioembolic strokes in multiple vascular territories, AKI requiring SLED and E. coli and Klebsiella UTI (completed course 1/6/2022).  She was discharged from Facility to Facility on 1/6/22 by ambulance. At Facility, she complained of chest pain and was sent to ED on 1/6. EKG did not show acute ST-T changes concerning for ischemia. Her presentation is consistent with post-procedure pain. Currently, is receiving Tylenol and oxycodone for pain. TTE obtained 1/07 and showed mean tricuspid valve gradient of 16 mm Hg, likely represents high output state (eg. Anemia) rather than valve stenosis.  Patient tested COVID positive on 01/12. Patient had endorsed symptoms of dyspnea for which she received prn albuterol and scheduled duonebs, that she no longer requires. While inpatient her diuresis was increased to BID dosing, she will be discharged back on Lasix 40 daily with additional lasix PRN worsening edema or weight gain. She was also started on Digoxin for her RV dysfunction in the setting of elevated RVSP, however this was discontinued given issues with her hyperkalemia. Her INR remains elevated at time of discharge (thought to be secondary to Lokelma, and down-trending at the time of discharge). She will require daily INRs, with plans to resume warfarin at 1mg daily when her INR is 3.5 or less.  Her INR goal is 2.5-3.5. At this time she is stable for discharge back to Facility. Follow up with cardiology and nephrology.  Discharge Diagnoses      Chest pain - reproducible, MSK post surgical  -Continue pain control with Tylenol 1g TID and PRN Oxycodone  Pulmonary HTN  Severe RV dysfunction Pulmonary edema - improved, on baseline O2 (3L) TTE 1/7:  EF 65, RV severely dilated, RVSP 60mmhg  - Continue PO Lasix 40 mg daily (HOLD UNTIL SUNDAY 1/30/2022)  - Additional Lasix 40 qday PRN weight gain >2lbs in one week or worsening peripheral edema  - follow up with cardiology within 14 days   COVID-19, off isolation precautions on 1/22 Tested positive 1/12 - Encourage IS use    Paroxysmal Atrial fibrillation  Cardioembolic strokes Severe Mitral valve stenosis s/p mechanical mitral valve replacement 12.10.2021  Severe tricuspid regurgitation s/p tricuspid valvuloplasty with ring  -Daily INR  - Goal INR 2.5 - 3.5  - Warfarin 1mg daily, HOLDING until INR is 3.5 or less - Continue metoprolol tartrate 50 mg bid   ESRD s/p renal transplant 3/2020  -continue mycophenolate 500mg bid, tacrolimus 9mg qam, and prednisone 5mg daily  - follow up with Nephrology within 14 days  T2DM  -Lantus 30 U QHS  -Lispro 22U with meals  -SSI     DISCHARGE ORDERS TO FACILTY   Patient Information  Patient:      Age: 60 Years  Sex: Female    Admit Date:  01/06/2022        Discharge Date:  01/28/2022   Visit Information  Attending Provider: MD,  Accepting Facility Name:    Health Status  Discharge Diagnosis  Diagnoses: Chest pain; Contact with and (suspected) exposure to covid-19  Vital Signs at Discharge Vital Signs (midnight yesterday to current) Parameter                    Last Charted  Minimum  Maximum                          Temperature                      36.3      (01/28 08:44) 36.3      (01/28 08:44) 36.5      (01/27 05:12)  Heart Rate                      84        (01/28 08:44) 76        (01/27 05:12) 87        (01/27 09:00)  Resp Rate                      18        (01/28 08:44) 16        (01/27 00:42) 20        (01/27 09:00)  NIBP                      120/63    (01/28 08:44) 111/61    (01/27 09:00) 142/78    (01/28 03:48)  SpO2                      96        (01/28 08:44) 94        (01/27 16:00) 99        (01/27 05:12)  Pain Score                      6         (01/28 09:02) 0         (01/28 03:48) 8         (01/27 14:14)   Post-Discharge Orders Warfarin Management If necessary, indication: Prosthetic Heart Valve If necessary, duration: Lifelong If necessary, target INR: 2.5 - 3.5  Skin/Wound Care None   Physical Therapy Evaluate and treat  Weight-Bearing Weight bearing as tolerated  Brace and Splint Care None  Occupational Therapy Evaluate and treat  Speech Therapy None  Diet Diabetic Diet, Adult (carbohydrate consistent) :  Ordered on 01/27/22 11:47:00 CST, Meal Start Time Breakfast 0700 to 0900, Diet Modifications Sodium, 4 gram | Potassium, Low  Tube Feeding None   Drains & Tubes None   IV Antibiotics +/- PICC or Port Care None   Respiratory Therapy None   Additional Orders: none   Discharge to Facility:  Further orders to be followed by the patient's PCP or other supervising physician at facility.        Other Diagnoses   Ongoing  Anemia  BMI 40.0-44.9, adult  Carotid artery stenosis  Esophageal Reflux  ESRD on hemodialysis  Fluid overload  Gastro-esophageal reflux disease  HYPERTENSION  Hypothyroid  Nuclear sclerosis  Opioid use agreement exists  Renal transplant recipient  Secondary hyperparathyroidism of renal origin  Severe obesity  Thoracic back pain  Type 2 diabetes mellitus  Historical  No qualifying data    Consultants  Medicine Nephrology    PMR     Discharge Disposition  Rehabilitation Facility    Medications  New, Changed, or Refilled Medications  atorvastatin (atorvastatin 10 mg) 20 mg, 2 Tablet(s), Oral, Daily, 60 Tablet(s), 0 Refill(s)    furosemide (furosemide 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, PRN: weight gain >2lbs in one week or increasing lower extremity swelling, 30 Tablet(s), 0 Refill(s)    furosemide (furosemide 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, HOLD until 1/30, 60 Tablet(s), 0 Refill(s)  Instructions:HOLD until 1/30  insulin glargine (Lantus insulin Solostar Pen 10 30 units, Subcutaneous, At Bedtime, 6 mL, 0 Refill(s) Comments: 1 Box = 15 mL (5 Pens)   insulin lispro (insulin lispro 100 units/mL inje 22 units, Subcutaneous, tid w/Meals, 7.5 mL, 0 Refill(s)    insulin lispro (insulin lispro 100 units/mL inje 1-7 units, Subcutaneous, tid w/Meals, << Sliding Scale Comments >>  150 - 199   1 units Call if less than 80  200 - 249   2 units   250 - 299   3 units   300 - 349   4 units   350 - 399   5 units   400 - 449   6 units   450 - 499   7 units Call if greater  Instructions:<< Sliding Scale Comments >>150 - 199   1 units Call if less than 80200 - 249   2 u  magnesium oxide (magnesium oxide 400 mg (241.3 m 400 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    melatonin (Melatonin 3 mg) 6 mg, 2 Tablet(s), Oral, At Bedtime, PRN: as needed for sleep, 60 Tablet(s), 0 Refill(s)    metoprolol (metoprolol tartrate 50 mg) 50 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    polyethylene glycol 3350 (MiraLax oral powder fo 17 g, Oral, Daily, PRN: Constipation, 12 Each, 0 Refill(s)    warfarin (warfarin 1 mg) 1 mg, 1 Tablet(s), Oral, Daily, HOLD until INR is <3.5, 60 Tablet(s), 0 Refill(s)  Instructions:HOLD until INR is <3.5    Medications to be Continued  acetaminophen (Tylenol Extra Strength 500 mg) 1,000 mg, 2 Tablet(s), Oral, q6h, PRN: as needed for pain    ergocalciferol (ergocalciferol 1.25 mg (50,000 i 50,000 IntUnits, 1 capsule(s), Oral, qWeek    ferrous fumarate (ferrous fumarate 324 mg (106 m 324 mg, 1 Tablet(s), Oral, Daily    glucagon (glucagon 1 mg/0.2 mL subcutaneous solu 1 mg, Subcutaneous, Once, PRN: Low Blood Sugar Symptoms    oxyCODONE (oxyCODONE 5 mg) 5 mg, 1 Tablet(s), Oral, q6h, PRN: as needed for pain, 0 Refill(s)    pantoprazole (pantoprazole 40 mg oral delayed re 40 mg, 1 Tablet(s), Oral, Daily    predniSONE (predniSONE 5 mg) 5 mg, 1 Tablet(s), Oral, Daily    ramelteon (ramelteon 8 mg) 8 mg, 1 Tablet(s), Oral, At Bedtime, PRN: Insomnia    senna (Senna 8.6 mg) 8.6 mg, 1 Tablet(s), Oral, bid    tacrolimus (Envarsus XR 1 mg , extended release) 1 mg, 1 Tablet(s), Oral, qAM, take with two 4 mg tablets for total dose of 9 mg daily  Instructions:take with two 4 mg tablets for total dose of 9 mg daily  tacrolimus (Envarsus XR 4 mg , extended release) 8 mg, 2 Tablet(s), Oral, qAM, take with 1 mg tablet for total dose of 9 mg daily  Instructions:take with 1 mg tablet for total dose of 9 mg daily    Discontinued Medications  QUEtiapine (QUEtiapine 25 mg) 25 mg, 1 Tablet(s), Oral, qAM    QUEtiapine (QUEtiapine 50 mg) 50 mg, 1 Tablet(s), Oral, At Bedtime    rosuvastatin (rosuvastatin 10 mg) 10 mg, 1 Tablet(s), Oral, qEvening    sodium zirconium cyclosilicate (sodium zirconium 10 g, Oral, bid       Physical Exam at Discharge  Vitals & Measurements  T: 36.4 °C  TMIN: 36.3 °C  TMAX: 36.6 °C  HR: 91  RR: 15  BP: 120/52  SpO2: 93%  WT: 93.6 kg  BMI: 40.5      General: a well appearing female in no acute distress  HEENT: no icterus, no conjunctivitis, hearing grossly normal  Cardiovascular: Normal S1 and S2 with normal rate and rhythm.  No murmurs, rubs or gallops are heard.  Pulmonary: Lungs are clear to auscultation in all lung fields without crackles or wheezes.  GI:  Abdomen is soft and non-tender with normal bowel sounds.  Musculoskeletal:  Normal strength throughout.  No deformity.  Neuro:  EOM intact.  Able to move all extremities spontaneously. RUE tremor  Psychiatric: Appropriate mood and affect.  Follow Up Appointments     Follow Up Appt Cardiology, Clinic Name/Phone: Cardiology Clinic, Provider Name: MD, , Within 14 Days, No tests, Reason for Follow Up Clin f/u hospital discharge   Follow Up Appt Cardiology, Clinic Name/Phone: Cardiology Clinic, Provider Name: NO , PREFERENCE, Within 1 Month, No tests, Reason for Follow Up Clin hospital discharge, chest pain   Follow Up Appt Nephrology, Clinic Name/Phone:  Nephrology Clinic, Provider Name: MD, Within 14 Days, No tests, Reason for Exam hospital discharge, hx renal transplant   Follow Up Appt Pulmonary Adult, Clinic Name/Phone: Pulmonary Clinic, Provider Name: FNP, Within 7 Days, No tests, Reason for Exam pulm htn, rtc 3 mo    Appointment Type  When  With  Where  Contact Information  Status   DC2 02/01/2022 10:40 AM CST FNP, Cardiology     Nursing/Other Orders   Diabetic Diet, Adult (carbohydrate consistent). Ordered on 01/10/22 14:57:00 CST, Meal Start Time Breakfast 0700 to 0900, Diet Modifications Sodium, 4 gram   Intake and Output (I&O). 01/07/22 0:38:00 CST, Continuous Order, total every 24 hours   Sternal Precautions. 01/07/22 1:18:00 CST, Continuous Order   Activity As Tolerated. 01/07/22 0:38:00 CST, Continuous Order, Advance as tolerated   Code Status. Code Status Description: Full Code     Addendum by MD, on January 28, 2022 12:21:32 CST (Verified)  I performed the history and examination of the patient and discussed the patient?s management with the resident . I reviewed the note by the resident and agree with those documented findings and plan of care.