Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Aspiration joint, Asthenia, C-reactive protein increased, COVID-19
Clinical narrative: Date of Admission: 8/31/2023   Date of Discharge: 9/11/2023   Issues to be Addressed at Follow-up: 1. Determine duration of colchicine. 2. Adjust insulin/metformin regimen as appropriate. 3. Adjust metoprolol, lisinopril as appropriate. 4. Long term nutrition, physical conditioning.   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   9/10/2023 11:00 AM AFB SMEAR AND CULTURE Preliminary JOINT   9/10/2023 11:00 AM FUNGAL CULTURE In process JOINT   9/10/2023 11:00 AM ANAEROBIC CULTURE In process JOINT   9/10/2023 11:00 AM BODY FLUID CULTURE Preliminary SYNOVIAL FLUID   9/7/2023  5:36 PM BLOOD CULTURE 2 Preliminary BLOOD   9/7/2023  5:30 PM BLOOD CULTURE Preliminary BLOOD   9/4/2023  5:25 PM CORTISOL In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? DECONDITIONING   ? HYPOMAGNESEMIA   ? VITAMIN D DEFICIENCY   ? SEVERE PROTEIN CALORIE MALNUTRITION   ? DM 2 W HYPERLIPIDEMIA   ? DM 2 W CKD STAGE 3A (GFR 45-59) W HTN   ? HTN (HYPERTENSION)   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? ATRIAL FIBRILLATION, PERMANENT W PROTHROMBOTIC STATE   ? HEART FAILURE W NORMAL LVEF >=50%, UNSPECIFIED ACUITY   ? HYPOTHYROIDISM     Resolved Hospital Problems   Diagnosis Date Resolved ? ACUTE CYSTITIS 09/06/2023     Discharge Disposition: SNF   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Reason for Hospital Admission (Admitting Diagnosis):  COVID infection, deconditioning   Hospital Course and Significant Findings: Per Dr. on 9/6: Pt is a 84 y/o female,) with h/o atrial fibrillation, hypertension, HFpEF, diabetes mellitus type II, diabetic chronic kidney disease.  At baseline, pt is ambulatory (uses a cane) and independent of ADLS (lives at home with daughter.)    Admitted on 9/1/2023 for generalized weakness.   Found to have Covid19 positive and UA concerned of UTI. Chest x-ray in the ED: low lung volumes, left basilar patchy opacity likely atelectasis change.  Not hypoxic.    During this hospital course:  ? Completed 3 days of Remdesivr 9/1-9/3/2023. ? Completed 5 days of Ceftriaxone 9/1-9/5/2023 for cystitis.  Urine culture grew mixed flora.   ? Deconditioning & maximal assist out of bed.   ? PT recommended daily PT. ? Plans to discharge pt to SNF for daily PT.   ? Has sitter for safety - impulsive & trying to get out of bed herself & unable to re-direct patient (not combative.)                 9/5/2023 ? Impulsive and trying to get out of bed per sitter. ? Children came to feed her.    9/6 ? PT moved pt out of bed to chair this am.   ? Max assist ? Sitter ? Updated pt's son (night shift RN @ Facility) this evening - son plan for B&C post SNF stay.     I took over care on 9/7.   By then, pt had received 3 doses of RDV on admission. On 9/7, pt was noted to have low grade fever of 100.4 F, which resolved with a dose of tylenol. Respiratory status remained stable on RA. Pt had no symptoms. Repeat CRP was increased compared to on admission. INR had been therapeutic on home warfarin throughout course, thus VTE was unlikely. Routine sepsis workup was sent with CXR, UA/urine cx, blood cx. CXR showed no interval change since admission. UA was without pyuria. Fever was attributed to COVID. RDV was resumed for 2 additional doses.    On 9/7, behavioral disturbance resolved. Sitter was removed. Pt was noted to be more fatigued than usual and had decreased activity level. PO intake remained stable. Pt had no recurrence of confusion/disorientation or behavioral disturbance for remainder of hospital course.   On 9/9, pt completed 5th dose of RDV. Blood cx remained negative for 48 hours. Pt remained afebrile. However, pt was noted to have acute left knee pain, swelling, warmth, and decreased ROM due to pain. Clinical picture was suggestive of gout/pseudogout flair up. Suspicion for septic arthritis was low. L knee XR showed moderate joint effusion. CRP and ESR were elevated (although nonspecific in the setting of COVID infection). Orthopedic surgery was consulted.   Empiric colcichine was started followed by symptomatic improvement by the following day. Per ortho evaluation, this was gout vs pseudogout vs COVID related arthritis vs reaction to trauma (as pt had fallen prior to admission). Pt underwent knee aspiration at bedside. Synovial fluid studies showed no crystals and significant WBC/PMN. Empiric colchicine was continued, per ortho.   Pt was deemed stable for discharge to SNF. Placement was secured. However, family declined SNF due to location and appealed the discharge. Pt completed isolation period for COVID by the end of the day on 9/10.   On 9/11, knee pain and swelling continued to improve. Pt was accepted at SNF at location of choice by family. Colchicine was prescribed on discharge. Prior home glipizide was replaced by insulin regular sliding scale. Prior home lopressor does was decreased to half during course and continued at lower dose on discharge. Prior lisinopril was continued without change. Thiamine, multivitamin, vitamin D were prescribed.   Vital signs: BP 147/75  | Pulse 66  | Temp 98.5 °F (36.9 °C)  | Resp 16  | Ht 5'  | Wt 48.6 kg (107 lb 2.3 oz)  | SpO2 96%  | Breastfeeding No  | BMI 20.93 kg/m²    Physical Exam on day of discharge: General appearance - frail; NAD HEENT - normocephalic, atraumatic Neuro - alert, answers yes/no questions appropriately, sitting upright in chair Heart - normal rate, regular rhythm, normal S1-S2. No murmurs/gallops/rubs Lungs - normal work of breathing on RA. CTAB. No crackles/wheezes/rhonchi Abdomen - normoactive BS, soft, non distended, nontender Extremities - L knee swelling, tenderness resolving, normal ROM Skin - warm, dry   Primary Procedures:  None   Secondary Procedures: None   Complications: none   Consults:  ORTHOPEDIC MEDICINE - INITIAL INPATIENT CONSULTATION. ORTHOPEDIC MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author (M.D.) File Time 9/11/2023  6:03 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 8/31/2023  ED to Hosp-Admission (Discharged) on 8/31/2023  ED to Hosp-Admission (Discharged) on 8/31/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HYPOTHYROIDISM  HEART FAILURE W NORMAL LVEF >=50%, UNSPECIFIED ACUITY  ATRIAL FIBRILLATION, PERMANENT W PROTHROMBOTIC STATE  ACUTE CYSTITIS Resolved  COVID-19 DISEASE  DECONDITIONING  DM 2 W CKD STAGE 3A (GFR 45-59) W HTN  DM 2 W HYPERLIPIDEMIA  SEVERE PROTEIN CALORIE MALNUTRITION  HYPOMAGNESEMIA  VITAMIN D DEFICIENCY  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  HTN (HYPERTENSION) Care Timeline  09/01   Admitted from ED (Observation) 1544 09/02   Admitted 1438 09/11   Discharged 1822  Discharge   SNF - Skilled bed (or Subacute)   SNF Orders (Printed 9/11/2023)   Follow-Ups: Follow up with CENTER-SNF Medication List at Discharge   acetaminophen 650 mg Oral EVERY 4 HOURS AS NEEDED, . Do not exceed 10 tablets in 24 hours. Do not exceed 4,000 mg of acetaminophen per day from all sources  bisacodyl 10 mg 1 Suppository Rectal DAILY AS NEEDED, . Use as 2nd line treatment if 1st line treatment is ineffective  blood sugar diagnostic Use 1 strip as directed 2 times a day to measure blood sugar  blood-glucose control, normal Use as directed with blood glucose meter  blood-glucose meter Use as directed to test blood sugar  cholecalciferol (vitamin D3) 2,000 Units Oral DAILY, (Resume on 11/23/2023 after completed 12 weeks of high dose vitamin D supplement)  colchicine 0.6 mg Oral DAILY  ergocalciferol (vitamin D2) 50,000 Units Oral WEEKLY, (Every Wednesday through 11/22/2023)  famotidine 20 mg Oral EVERY BEDTIME  glipizide 10 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  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  lancets 30 gauge Use 1 Each as directed 2 times a day to measure blood sugar  levothyroxine sodium 75 mcg Oral DAILY BEFORE BREAKFAST  lisinopril 10 mg Oral DAILY  magnesium oxide 400 mg Oral DAILY  melatonin 3 mg Take 1 tablet by mouth half-hour before bedtime  metformin HCl 250 mg Oral 2 TIMES A DAY, with food or as directed  metoprolol tartrate 12.5 mg Oral 2 TIMES A DAY WITH MEALS  multivitamin 1 tablet Oral DAILY  raloxifene HCl 60 mg Oral DAILY  simvastatin 20 mg Oral EVERY EVENING  thiamine HCl 100 mg Oral DAILY, Through 9/30/2023  warfarin sodium   2 mg Tab, Take by mouth as directed by Anticoagulation clinic  Patient on Warfarin and is followed by the Anticoagulation Clinic. Contact Anticoagulation Clinic.