Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Clostridium test, Condition aggravated, Cough, Creatinine renal clearance decreased, Dizziness
Clinical narrative: Hospitalized (12.26.21 - 1.3.22); COVID-19 positive (12.26.21); Fully vaccinated - J&J x1 Home covid + test  Discharge Summary       Admission Date: 12/26/2021 Discharge Date: 1/3/2022    Active Hospital Problems   Diagnosis Date Noted POA o Pneumonia due to COVID-19 virus 12/27/2021 Unknown   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA o Dilated aortic root (HCC) 10/30/2021 Unknown o LFT elevation 12/20/2020 Unknown o Memory disturbance 09/07/2020 Unknown o Gastroesophageal reflux disease without esophagitis 09/07/2020 Unknown o Chronic gout of multiple sites 09/07/2020 Unknown o Peripheral vascular disease, unspecified (HCC) 09/07/2020 Unknown o Dry eyes, bilateral 07/10/2020 Unknown o Non-proliferative diabetic retinopathy, left eye (HCC) 07/10/2020 Unknown o Episode of recurrent major depressive disorder (HCC) 02/22/2020 Unknown o Skin cancer   Unknown o Shortness of breath 05/22/2019 Unknown o CVA (cerebral vascular accident) (HCC) 04/29/2019 Unknown o Diplopia 04/23/2019 Unknown o MGUS (monoclonal gammopathy of unknown significance) 02/13/2019 Unknown o History of carotid artery dissection 05/30/2018 Unknown o Focal epilepsy (HCC) 04/04/2018 Unknown o History of common carotid artery stent placement 02/26/2018 Unknown o History of kidney stones 02/26/2018 Unknown o History of prostate cancer 02/26/2018 Unknown o Type 2 diabetes mellitus without ophthalmic manifestations (HCC) 02/09/2018 Unknown o Posterior vitreous detachment, right 06/19/2015 Unknown o Hyperopia, bilateral 06/19/2015 Unknown o Arthropathy of cervical facet joint   Unknown o OSA (obstructive sleep apnea) 07/25/2011 Unknown o Hypothyroidism 05/05/2011 Unknown o HTN (hypertension), benign   Unknown o Coronary artery disease involving native coronary artery of native heart without angina pectoris   Unknown o Hyperlipidemia 08/05/2009 Unknown     Discharge Disposition:     Active Issues Requiring Follow-up:    CAP : Completed abx therapy.  Outpatient follow-up with PCP in 5-7 days.  Chest x-ray in 6 weeks to ensure resolution.  Close monitoring of symptoms.    Pending Labs    Order Current Status   Peripheral Blood Culture Preliminary result   Peripheral Blood Culture Preliminary result       DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Community acquired pneumonia, unspecified laterality Pneumonia due to COVID-19 virus COVID-19     a 79-year-old gentleman with past medical history significant for DM 2, carotid artery dissection, CAD, hypertension, hyperlipidemia, MGUS, hypothyroidism, hepatitis a, prostate cancer in remission, obesity, CVA who was admitted on 12/26/2021 for evaluation of symptoms of generalized weakness/nonproductive cough/shortness of breath.  Had tested positive for COVID-19 on 12/22 at home.  Monoclonal antibody infusions were to be arrange but patient had not received them.  In the emergency department patient was hypoxic with ambulation and was extremely weak and dizzy.  Imaging with chest x-ray showed left basal infiltrate.  CPAP was suspected and patient was started on Rocephin and azithromycin.  Admitted to internal medicine for continued care.   Post admission given patient was stable on room air no treatment was started for the COVID-19.  Blood cultures were obtained.  Urine strep, urine Legionella were negative.  Procalcitonin was negative as well.  Antibiotic therapy with Rocephin and azithromycin was continued.  Blood cultures remain negative at 48 hours.  PT/OT evaluated the patient and recommended discharge home with assist.  Pulmonary have evaluated the patient and not see the need for oxygen at home.  Patient being discharged in a stable condition with recommendations to follow up with PCP in the next 5-7 days. CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:    Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 153/97  | Pulse 85  | Temp 36.9 °C (Oral)  | Resp 20  | Ht 1.829 m  | Wt 114 kg  | SpO2 90%  | BMI 34.09 kg/m²    Physical Exam Constitutional:      Appearance: He is well-developed.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:     Cervical back: Normal range of motion.  Skin:    General: Skin is warm.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.        Lab Results Last 24 Hours Recent Results (from the past 24 hour(s)) Clostridioides difficile Toxin     Status: Normal   Specimen: Rectum; Stool Result Value Ref Range Status   C difficile Toxin Negative Negative Final POCT GLUCOSE NOVA METER AUTO     Status: Abnormal Result Value Ref Range Status   Glucose, POC 135 (H) 70 - 99 mg/dL Final   Narrative   Basic Metabolic Panel (BMP)     Status: Abnormal Result Value Ref Range Status   Sodium Level 142 134 - 146 mmol/L Final   Potassium Level 3.8 3.4 - 5.0 mmol/L Final   Chloride 107 98 - 112 mmol/L Final   HCO3 24 21 - 29 mmol/L Final   Anion Gap 11 9 - 18 mmol/L Final   Glucose Level 136 (H) 70 - 99 mg/dL Final   Blood Urea Nitrogen 17 8 - 20 mg/dL Final   Creatinine 1.01 0.60 - 1.30 mg/dL Final   MDRD eGFR >60 >=60 mL/min/1.73 m2 Final   CG eCrCl 65 mL/min/1.73 m2 Final   Calcium Level Total 8.5 (L) 8.6 - 10.4 mg/dL Final Complete Blood Count without Differential     Status: Abnormal Result Value Ref Range Status   White Blood Cell 9.68 4.00 - 10.80 x10*3/uL Final   Red Blood Cell 4.88 4.60 - 6.00 x10*6/uL Final   Hemoglobin 13.2 (L) 14.0 - 18.0 g/dL Final   Hematocrit 42.4 42.0 - 52.0 % Final   Mean Cell Volume 86.9 80.0 - 100.0 fL Final   Mean Cell Hemoglobin 27.0 27.0 - 33.0 pg Final   NRBC Absolute Count 0.00 0.00 - 0.01 x10*3/uL Final   NRBC Automated 0.0 0.0 - 0.1 %WBC Final   Mean Cell Hemoglobin Concentration 31.1 (L) 32.0 - 37.0 g/dL Final   Red Cell Diameter Width 15.1 11.0 - 16.0 % Final   Platelet 302 140 - 400 x10*3/uL Final   Mean Platelet Volume 10.9 7.4 - 11 fL Final POCT GLUCOSE NOVA METER AUTO     Status: Abnormal Result Value Ref Range Status   Glucose, POC 142 (H) 70 - 99 mg/dL Final   Narrative Admission Date: 12/26/2021 Discharge Date: 1/3/2022    Active Hospital Problems   Diagnosis Date Noted POA o Pneumonia due to COVID-19 virus 12/27/2021 Unknown   Resolved Hospital Problems No resolved problems to display.   Pre-Existing Active Problems   Diagnosis Date Noted POA o Dilated aortic root (HCC) 10/30/2021 Unknown o LFT elevation 12/20/2020 Unknown o Memory disturbance 09/07/2020 Unknown o Gastroesophageal