Date of Admission: 9/13/2023   Date of Discharge: 9/20/2023   Issues to be Addressed at Follow-up: Ongoing speech therapy for swallowing Ongoing physical therapy Weaning oxygen to off as tolerated Any signs of infection?   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/21/2023 to 9/21/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? HYPONATREMIA   ? BRONCHIECTASIS       On CT 9/17/23   ? DYSPHAGIA FOLLOWING CEREBROVASCULAR DISEASE   ? AV BLOCK, FIRST DEGREE   ? ACUTE STROKE DUE TO ISCHEMIA, UNSPECIFIED TYPE AND ARTERY   ? DM 2 WO RETINOPATHY   ? DYSPHAGIA       2023 - Per recent SNF admission -  his dysphagia is likely contributing to aspiration /risk of future aspiration.  Referred to GI but he and wife ?declined?  Will continue to discuss and offer resources.   ===== Caused by esophageal dysmotility No stricture at EGD April 2015, Empiric savary dilation to 15 cm did not change symptoms Esophageal motility testing 8/7/15 showed failed swallow 75% of the time and findings c/w dymotility Advised to use water after most swallows and avoid extremes of hot and cold to prevent spasm.   ? HTN (HYPERTENSION)        7/20/2022  "RN Message Notes: KEY SYMPTOMS AND ASSESSMENT:  Wife calling for member is bedridden not new.. 07/19 blood pressure 103/75 does not know pulse.  Lasix and blood pressure medication..  Denies chest pain or shortness of breath.. Dizziness with weakness weight loss..  Normal urination stopped taking lasix 07/18. Diffcultly walking due to weakness that is generalized worsening.. Uses lift intermittent falling" Notes BP increasing again. Stopped Lasix, notes edema slowly increasing.   A/P: Was running low, increasing again. Will send in blood pressure readings over next 1-2 weeks to see if medication doses need change. Will monitor edema and restart Lasix daily if increasing.   ? HYPERLIPIDEMIA     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  SNF   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 84 Y male with pmh of recent left pontine stroke with right carotid occlusion 9/3/23,  DM2 on insulin, HYPERTENSION, HKP, chronic dysphagia/esophageal dysmotility who presented to the ED 9/13 with hypoxemic resp failure due to covid pneumonia.  Pt completed remdesivir, decadron.  CT chest shows bronchiectasis at bases.  No signs of ongoing infection.  He remains on 1-2 liters of oxgyen.  Duonebs started TID for sputum clearance.  Pt to complete 4 more days of asa (and protonix while on dual antiplatelet therapy), and to continue plavix for life.  No statin due to previous intolerance with muscle aches.  Econ sent to Vasc surgery regarding high grade right cartotid stenosis.   His swallow has improved and he is doing well on soft and thins.  Pt stable for discharge back to SNF.  Pt to remain in isolation through 10/2/23 due to covid pneumonia.   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  covid pneumonia   Complications: none   Consults:  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 9/20/2023 12:00 PM Author Type Physician Status Addendum Last Editor  (M.D.) Specialty Critical Care Medicine Hospital Acct # Admit Date 9/13/2023  ED to Hosp-Admission (Discharged) on 9/13/2023  ED to Hosp-Admission (Discharged) on 9/13/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Forms:   STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HYPERLIPIDEMIA  HTN (HYPERTENSION)  DM 2 WO RETINOPATHY  DYSPHAGIA FOLLOWING CEREBROVASCULAR DISEASE  AV BLOCK, FIRST DEGREE  BRONCHIECTASIS  COVID-19 DISEASE  DYSPHAGIA  ACUTE STROKE DUE TO ISCHEMIA, UNSPECIFIED TYPE AND ARTERY  HYPONATREMIA Care Timeline  09/13   Admitted from ED (Observation) 1553 09/15   Admitted 1524 09/20   Discharged 1715  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 9/20/2023)   Discharge Orders 30 DAY EVENT MONITOR, CV Medication List at Discharge   acetaminophen 650 mg Oral EVERY 4 HOURS AS NEEDED, (temperature > 100.4). Do not exceed 6 tablets in 24 hours. Do not exceed 3,000 mg of acetaminophen per day from all sources  aspirin 81 mg Take 1 tablet orally daily for 4 days, then stop  bisacodyl 10 mg 1 Suppository Rectal DAILY AS NEEDED, . Use as 2nd line treatment if 1st line treatment is ineffective  blood sugar diagnostic Use as directed to measure blood glucose once daily.  chlorhexidine gluconate 0.12 % 15 mL Mucous Membrane EVERY 12 HOURS  cholecalciferol (vitamin D3) 1,000 Units Oral DAILY  clopidogrel bisulfate 75 mg Oral DAILY, Last dose is 9/24  gabapentin 100 mg Oral 3 TIMES A DAY  glipizide 5 mg Oral EVERY MORNING BEFORE A MEAL  glucagon 1 mg If receiving insulin and signs or symptoms of hypoglycemia are present, give snack. If patient is not responsive to snack, give glucagon subcutaneously or intramuscularly and notify physician on-call. Recheck glucose in 15 minutes  hydrochlorothiazide 25 mg Oral DAILY, . Labs due  insulin regular, human 100 unit/mL If BG <60 & alert give snack, check BG w/in 30 min, hold insulin. Call MD if unresponsive. If BG 60-149 do not give insulin; If BG 150-199 give 2 units; 200-249 give 4 units; 250-299 give 6 units; 300-349 give 8 units; 350-399 give 10 units; 400-449 give 12 units; >450 give 14 units & check in 2 hrs & notify MD/NP if glucose still >450  ipratropium/albuterol sulfate 0.5 mg-3 mg(2.5 mg base)/3 mL 3 mL NEBULIZATION -UNSPEC 3 TIMES A DAY  metformin HCl 500 mg Oral 2 TIMES A DAY, with food. LABS DUE  pantoprazole sodium 40 mg Oral DAILY  pravastatin sodium 20 mg Oral DAILY