Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Influenza virus test negative, Insulin-requiring type 2 diabetes mellitus, International normalised ratio increased, Interstitial lung disease, Intervertebral disc space narrowing
Clinical narrative: ED to Hosp-Admission Current   9/5/2021 - present (3 days) Hospital    Hospital Problems        POA   * (Principal) Pneumonia due to COVID-19 virus Yes       Sepsis (HCC) Yes       Mental status alteration Yes       Supratherapeutic INR Yes                    Plan     Chief Complaint Patient presents with ? Weakness - Generalized     1. Mental status alteration                                    Sepsis     -suspect secondary to infection                                         -follow neuro exam 2.                                           -hx covid now with dexamethasone, not hypoxic                                         -possibly pulmonary source                                         -s/p blood cx                                         -iv abx                                         -iv fluids 3. COVID PNA without hypxia                                         -contact and droplet isolation                                          -obtain and trend markers                                         -titrate o2 satn>95%                                         -continue dexamethasone 6 more days 4. PAF                                         -tele                                         -rate control and anticoagulation with coumadin 5. supratherapeutic INR                                         -hold coumadin                                         -daily INR; pharmacy to dose 6. Type II dm-insuln dep-uncontrolled                                         -CCD diet                                         -accu check qac,hs with ss 7. 5mmRUL nodule                                         -identified last hospitalization; follow outpt. Thoracic surgery aware 8. Elevated troponin                                          -tele                                         -trend troponins; suspect demand 9. HTN                                         -follow bp; cpm 10. HLD 11. Code Status- Full code 12. DVT prophylaxis                                        -coumadin/as above 13. All  medical problems listed above are present upon admission 14. Role of the hospitalist is explained to the patient in some detail questions answered to his satisfaction  Pt is an 79 y.o. male.  The past medical history significant for hospital discharge  on September 2.  That time the patient did have chest pain with a non-STEMI was diagnosed  with Covid (He had been previously vaccinated).  Patient was given Decadron in the ED and  was not hypoxic.This patient presents to the emergency room from home via his wife.  Patient  continues to haveChills, diarrhea, cough and altered mental status.  Patient's wife notes that  he has had diarrhea on and off since Friday he has been moaning and unable to tell her what  is wrong.Decreasing oral intake, using his medication and care.  On entry to the hospital Patient's wife has concerns regarding her ability to care for her husband. T-max in the ER is 101.5 patient met sepsis criteria.  Labs include BUN/creatinine of 49 of 1.9, Magnesium 1.5, INR 4.1, troponin of 0.03, normal white count, negative urinalysis. CT scan head is unremarkable.  Chest x-ray shows wispy opacity within the peripheral lungs  left greater than right(keeping with a Covid pneumonia.)  Lactic acid is negative. Procalcitonin 0.26.  The emergency room the patient denies chest pain, pressure,  palpitations, syncope.  Patient has a history of bilateral AKA and his sacral area Was visualized there is no open wound.  The patient appears slightly confused in the ED By my assessment can give a only moderate history.  Cultures were obtained and IV antibiotics Initiated.  Patient is now seen at the request of ED staff.