Received Mar 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 6 | HG6396 | UN / UN |
Name: Date of Birth: 6/XX/19XX (Age: 70 y.o.) Date of Admission: 3/5/2025 Date of Discharge: 3/9/2025 Consultants: neurology, neurosurgery Intern/Resident: n/a Hospital Course by Discharge Diagnoses: Intraparenchymal Hemorrhage and Subdural Hematoma -involving left frontal lobe, left tentorium and right lateral ventricle -appreciate neurosurgery input, no surgical intervention planned, keep systolic bp<150 -cont to hold any asa or ac at this time until resolved on serial imaging -stable for dc home per PT/OT recs, home therapy -f/u ct head ordered by neurosurgery Diabetes Mellitus -carb restrict, on ssi, glucose relatively controlled -cont home meds which includes jardiance, A1c 6.6 History of Substance Abuse -h/o endocarditis -mod-severe tricuspid regurg -cont home methadone Hypertension -increase valsartan, cont home spironolactone, resume home amlodipine Hyperlipidemia -cont statin Anxiety/Depression -cont citalopram, buspirone BPH-cont tamsulosin Tobacco Use -counsel cessation, nicotine patch Microcytosis without Anemia -fe studies normal, likely beta thalassemia Brief Admission History/Reason for Admission: Per H&P: 70 y.o.male with PMHx of alcohol abuse, opiate abuse, MDD, diabetes type 2, BPH, hypertension, osteoporosis who presented to the hospital overnight after an unwitnessed fall at home. His daughter, who is present for exam, states that she and her sister were with him and heard a loud thud around 2:00am. They went to check on their dad and he was on the ground in the bathroom. He does not recall the events of the fall or if he experienced any presyncopal symptoms. He is still unsure what occurred. He complains of a headache and is tired and slightly altered to orientation at this time, but denise any troubles with speech, hearing, numbness or weakness in his extremities or other focal neurologic deficits. He does not take ASA or other anticoagulation. Discharged to Home.