Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Fibrin D dimer, Gait disturbance, Gastrooesophageal reflux disease, Granuloma, Haemorrhage
Clinical narrative: ED to Hosp-Admission  Discharged 10/5/2021 - 10/9/2021 (4 days)  Essential hypertension   Coronary artery disease  Monoclonal (M) protein disease, multiple 'M' protein   ** Principal problem Diarrhea, unspecified type  Pneumonia due to COVID-19 virus    Presenting Problem/History of Present Illness/Reason for Admission Cough Weakness SOB (shortness of breath) Liver cyst AKI (acute kidney injury) Lung granuloma Fall, initial encounter Abdominal pain, unspecified abdominal location Altered mental status, unspecified altered mental status type Diarrhea, unspecified type Non-intractable vomiting with nausea, unspecified vomiting type COVID-19 virus infection Patient is a 82 y.o. male   With medical history of CAD, myasthenia gravis, hypertension, hyperlipidemia, who presents to ER with complaints of diarrhea, nausea, vomiting, shortness of breath, mild cough, generalized weakness, frequent falling. Patient is an 82 y.o. male.  With medical history of CAD, myasthenia gravis, hypertension, hyperlipidemia, who presents to ER with complaints of diarrhea, nausea, vomiting, shortness of breath, mild cough, generalized weakness, frequent falling.   Patient reports that he has a mild productive cough and shortness of breath with exertion.  Patient has myasthenia gravis and usually walks with a cane or walker and he has been having difficulty ambulating for the last few days and has been falling.  Patient takes care of his wife who has dementia.  Per daughter, patient has been more confused and forgetful for the last few days.  At baseline patient is alert and oriented.   Patient is tested positive for Covid.  Labs remarkable for AKI.  He was given empiric antibiotic ceftriaxone, azithromycin, IV dexamethasone, DuoNeb's , 500 cc bolus normal saline in the ER.  Hospitalist is consulted for admission.   Hospital Course   Due to an episode of hypoxia as well as underlying immunocompromise state he was a started on IV Remdesivir and IV dexamethasone.  He was continued on IV fluids for his AKI and renal function started to improve.  He did not require further supplemental oxygen and CT of the chest was showing scant pneumonia only.  His renal function improved, clinically he was better and his mentation improved.  He was given higher dose of dexamethasone as he was being on chronic prednisone/immunosuppression. Patient is completing 5 dose of IV Remdesivir today.  He did well with the physical therapy and wished to go home without home health services/home PT.  Discussed with patient daughter regarding discharge planning. I advised him to take additional 5 days of oral dexamethasone and can switch to his regular dose of prednisone.  Chief Complaint Patient presents with ? Altered Mental Status     1. COVID-19 pneumonia: CT abdomen showed groundglass opacification at the bases bilaterally.  Will follow up with a CT chest. He Is currently saturating in low 90s on room air.  CRP is elevated.  Given his immunocompromised status, there is a risk of decompensation.  We will initiate treatment with remdesivir,dexamethasone. hold his home prednisone.  Monitor LFTs, D-dimer, inflammatory markers daily.  DVT prophylaxis with Lovenox.  Pulmonary toilet with incentive spirometry, pep, Mucinex.  He already received empiric antibiotics.  Will check procalcitonin, if negative, no need to continue antibiotics. 2. AKI: Baseline creatinine is around 1.0-1.1.  Creatinine on admission is 1.9.  Likely prerenal due to dehydration from vomiting, diarrhea: He  received 500 cc bolus normal saline. we will continue with gentle IV hydration for today. 3. Altered mental status: Likely metabolic due to AKI. Improving. patient is alert oriented during my evaluation.  CT head negative for acute abnormality 4. Generalized weakness: Likely due to Covid infection.  Check TSH, B12, vitamin D.  PT/OT evaluation 5. Coronary artery disease: Denies any chest pain.  Continue his home medications aspirin, statin, metoprolol, Imdur. 6. Myasthenia gravis: Continue his home medication CellCept, pyridostigmine.  Home prednisone is on hold as he is receiving IV dexamethasone.His neurologist increased cellcept to 1250 mg bid, per discussion with son, he is taking only 1000mg bid. Will continue the same dose. 7. MGUS: He follows with hematology at outpatient.  He gets skeletal surveys, lab work-up frequently.   8. Hypertension: Blood pressures currently borderline low.  Will resume his home medication amlodipine, metoprolol, Imdur with hold parameters. 9. Hyperglycemia: Due to chronic prednisone use.  Hold home Metformin . will monitor with sliding scale. 10. GERD: Continue PPI 11. Depression/anxiety: Continue Zoloft.   Total time spent: 70 minutes Daughter is updated over the phone.   o Nutrition: Heart healthy diet o VTE prophylaxis: SCD, subcutaneous heparin. o Full Code     Extended Emergency Contact Information   History of Present Illness     Patient is an 82 y.o. male.  With medical history of CAD, myasthenia gravis, hypertension, hyperlipidemia, who presents to ER with complaints of diarrhea, nausea, vomiting, shortness of breath, mild cough, generalized weakness, frequent falling.   Patient reports that he has a mild productive cough and shortness of breath with exertion.  Patient has myasthenia gravis and usually walks with a cane or walker and he has been having difficulty ambulating for the last few days and has been falling.  Patient takes care of his wife who has dementia.  Per daughter, patient has been more confused and forgetful for the last few days.  At baseline patient is alert and oriented.   Patient is tested positive for Covid.  Labs remarkable for AKI.  He was given empiric antibiotic ceftriaxone, azithromycin, IV dexamethasone, DuoNeb's , 500 cc bolus normal saline in the ER.  Hospitalist is consulted for admission.   I Have reviewed past medical history, surgical history, social history, family history, allergies, medications.