Date of Admission: 11/9/2023   Date of Discharge: 11/11/2023   Issues to be Addressed at Follow-up: Patient to resume ongoing medical care with MD COVID isolation ends on 11/19   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/9/2023  4:24 PM CROSSMATCH, ELECTRONIC In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) ACUTE HYPERCAPNIC RESPIRATORY FAILURE   ? PRESENCE OF CARDIAC PACEMAKER, NORMAL FUNCTION       Generator: St. Jude, model number 5626, serial number 1825814. Ventricular lead: St. Jude, model number 1646T/58, serial number UB212521 Implant date:  02/14/2008; for   a fib . DEPEND R WAVES ARE SUPER SLOW    ? LONG TERM ANTICOAGULANT THERAPY   ? CKD STAGE 3A (GFR 45-59)   ? DIASTOLIC HEART FAILURE, ACUTE   ? COPD   ? ANEMIA       hx of; Hgb in high 9s, low 10s. w/u completed 2009 - likely ACD vs. CRI. Pt prefers not to have transfusions - but will consider given low energy. On iron pills.   ? HTN   ? COVID-19 DISEASE   ? THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)     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: 92-year-old man with multiple medical problems including presence of mechanical mitral valve + atrial fibrillation on chronic anticoagulation, hypertension, hyperlipidemia, gout, anemia (normal EGD January 2017, no record of colonoscopy, and prior work-up consistent with anemia of chronic disease with normal B12 and folic acid levels), presence of permanent pacemaker, gout, COPD, hypertension, CKD stage IIIa, history of skin cancer, mild cognitive impairment and DNR/I status who is brought to the ED because family was concerned that his home oxygen saturations has been fluctuating with the lowest being 91% on 2 L and generalized feeling of unwellness including decreased appetite, headache, and myalgia over the last 5 days.  Patient daughter tested positive for COVID and today patient was found to be COVID-positive at home.  He denies any nausea or vomiting, no diarrhea, no cough, no PND or orthopnea, no chest pain, no reported weight gain and no fever or chills or diarrhea. At baseline he uses home O2 at 2 L/min and walks with a walker.             Active Hospital Problems   Diagnosis   ? (Principal) ACUTE HYPERCAPNIC/HYPOXEMIC RESPIRATORY FAILURE --Improved and actually better than baseline.  At baseline he uses 2 L of oxygen and today he is on 1 L. --Discontinue remdesivir and dexamethasone     COVID -19 ---disontinueD remdesivir and dexamethasone after 2 doses of each --- Isolation to end 11/19          HFpEF EF still preserved at 60 to 65% --- Continue Coreg --- Discontinue IV furosemide and resume oral low-dose furosemide -- Added  losartan --- Added empagliflozin --- Monitor electrolytes and glucose       COPD --- Antimuscarinic and beta agonist ----Titration of oxygen     ANEMIA     --- Status post transfusion 1 unit packed RBCs --- Continue to monitor         ? PRESENCE OF CARDIAC PACEMAKER, NORMAL FUNCTION       --Noted   ? LONG TERM ANTICOAGULANT THERAPY presence of mechanical mitral valve + atrial fibrillation on chronic anticoagulation,  ----Continue Coumadin     ? CKD STAGE 3A (GFR 45-59) --- Stable     ?     ?     ?           ? HTN  --- Complicated with history of hypotension requiring midodrine. --- Place midodrine on a as needed basis -----Adding losartan         Primary Procedures:      Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):      Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: DNR        Note Details  Author (M.D.) File Time 11/11/2023 10:43 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 11/9/2023  ED to Hosp-Admission (Discharged) on 11/9/2023  ED to Hosp-Admission (Discharged) on 11/9/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   SmartForms:   STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   ACUTE HYPERCAPNIC RESPIRATORY FAILURE  THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)  COVID-19 DISEASE  LONG TERM ANTICOAGULANT THERAPY  PRESENCE OF CARDIAC PACEMAKER, NORMAL FUNCTION  COPD  CKD STAGE 3A (GFR 45-59)  DIASTOLIC HEART FAILURE, ACUTE  HTN  ANEMIA Care Timeline  11/09   Admitted from ED 1450 11/11   Discharged 1634  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 11/11/2023)   Discharge Orders BICARBONATE BUN CHLORIDE CREATININE W GFR, CALCULATED GLUCOSE POTASSIUM SODIUM Medication List at Discharge   acetaminophen 500 mg Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply for asthma is 1 canister  allopurinol 300 mg Take 2 tablets orally daily after a meal (take 1 tablet in the morning, and 1 tablet in the evening) for gout prevention  carvedilol 3.125 mg Oral 2 TIMES A DAY  diclofenac sodium 1 % Apply 2 Grams to the hand(s) 2 times a day as needed for pain  empagliflozin 12.5 mg Oral EVERY MORNING  ferrous sulfate 325 mg Oral EVERY MON,WED,FRI  fludrocortisone acetate 0.1 mg Oral DAILY  fluticasone propion/salmeterol 100-50 mcg/dose 1 Puff Inhalation 2 TIMES A DAY  furosemide 40 mg Take one-half tablet by mouth daily as needed (Lower extremity swelling)  lactulose 10 g Oral 2 TIMES A DAY AFTER MEALS AS NEEDED  losartan potassium 25 mg Oral DAILY  lovastatin 40 mg Take 1 tablet orally at bedtime Avoid grapefruit or grapefruit juice with this medication.  midodrine HCl 5 mg Take 1 tablet every 8 hours if needed for when systolic blood pressure less than 95  multivitamin,therapeutic Takes one tablet daily  nitroglycerin 0.4 mg Sublingual  AS NEEDED, . May repeat 2 times every 5 minutes. Call 911 if pain persists longer than 5 minutes after the first dose. Continue to take the 2nd and 3rd doses if pain persists  warfarin sodium 4 mg Take by mouth as directed by Anticoagulation clinic