Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Creatinine renal clearance decreased, Dehydration, Diarrhoea, Disorientation, Escherichia infection
Clinical narrative: Hospitalized (12.23.21 - still admitted currently); COVID-19 positive (12.22.21); Fully vaccinated  - pfizer x2 - ED at HCF 12/22 H&P: Attestation signed by MD at 12/23/2021  4:40 PM I have personally interviewed and examined the patient on 12/23/2021.I agree with the documented findings and plan of care in his/her note.   Brief exam:    Sleeping but arousable Answers yes/no questions appropriate No increased work of breathing   Brief history and medical decision making: 80 y/o vaccinated female here with COVID pna, acute hypoxic RF. Worsening oxygen needs o/n, now on HFNC. Will add remdesivir after discussion with daughter, consider increasing to IV solumedrol if no improvement.   Expand All Collapse All     Hide copied text  Hover for details   HOSPITALIST  Admission History and Physical     CHIEF COMPLAINT lethargy     Assessment/Plan     ASSESSMENT Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Essential hypertension   Chronic lymphocytic leukemia (HCC)   Major neurocognitive disorder (HCC)   Anxiety      PLAN   Acute hypoxic respiratory failure 2/2 Covid pneumonia O2 sat 83% on room air at home for EMS  Covid + in ED 12/22 On 4L NC in ED-- now requiring 6L  Symptom onset: 12/18 Vaccinated (3/17, 4/10) CXR with bilateral patchy ill-defined airspace disease Decadron 6 mg IV Prone position as able/ IS Daily covid labs Consider remdesivir - will need to discuss with daughter   Vomiting Diarrhea Likely 2/2 Covid Denies abdominal pain  Received 1.5L of IVF in ED Anti-emetics prn Imodium prn   CLL Follows with Dr. heme/oncology WBC 31, at her baseline Monitor   AKI 2/2 dehydration Cr 1.11 (baseline ~ 0.8) Received 1.5L IVF in ED Hold ACE, ARB, HCTZ Monitor Avoid nephrotoxic agents as able   Essential hypertension CAD Continue toprol, ASA, statin Hold losartan, lisinopril, HCTZ   Dementia  Lives alone, has STM deficits Continue aricept Daughter is DPOA   Anxiety Continue home zoloft       Diet:  Heart Healthy VTE Prophylaxis:  Lovenox SubQ Code status: DNR/ DNI    Above assessment and plan discussed with Dr. whose insight is reflected above.       Subjective     HISTORY OF PRESENT ILLNESS Patient is a 80 y.o. female with past medical history significant for anxiety, CLL, hypertension, and dementia who presented to local ED with fatigue, vomiting, and diarrhea. Patient has STM issues and information largely obtained from daughter and medical record. Patient is vaccinated for Covid (3/17, 4/10/21). She began feeling ill on 12/18 with vomiting and diarrhea. She has had increasing lethargy over the last 24 hours. She was found to be hypoxic with saturation 83% on room air at home when EMS found patient. She was placed on 4L NC in ED with improvement in oxygen saturations. Labs were notable for BUN 52, creatinine 1.11, WBC 31. She was Covid-19 positive. Chest x-ray showed bilateral patchy ill-defined airspace disease. She was given decadron 6 mg IV, zofran 4 mg IV, and 1.5 L of IVF in ED. She was transferred to another hospital.         Patient Active Problem List Diagnosis ? Coronary artery disease due to lipid rich plaque ? Other hyperlipidemia ? Essential hypertension ? History of myocardial infarction ? Bilateral hearing loss, unspecified hearing loss type ? Arthritis of knee, right ? Chronic lymphocytic leukemia (HCC) ? Major neurocognitive disorder (HCC) ? Anxiety ? Pneumonia due to COVID-19 virus OBJECTIVE BP 115/59  | Pulse 76  | Temp 36.5 °C (Oral)  | Resp 20  | Ht 1.626 m  | Wt 67.8 kg  | SpO2 90%  | BMI 25.66 kg/m²  Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance.  HENT:     Head: Normocephalic.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Diminished throughout Nc in nares Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: Normal range of motion.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert. Mental status is at baseline. She is disoriented.     Comments: Disoriented to month and holiday Stated she was in urgent care, thought it was Fremont  Psychiatric:     Comments: Calm, cooperative, pleasant   1/4/22 progress notes: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN: Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Essential hypertension   Chronic lymphocytic leukemia (HCC)   Major neurocognitive disorder (HCC)   Anxiety   Moderate protein-calorie malnutrition (HCC)   Acute hypoxic respiratory failure 2/2 Covid pneumonia, improving  Covid + in ED 12/22 Symptom onset: 12/18 Vaccinated (3/17, 4/10).  No booster CXR with bilateral patchy ill-defined airspace disease Prone position as able/IS VBG without concerns.  Completed decadron/remdesivir.  Wean oxygen as able   E.Coli UTI -pan-sensitive -switched rocephin to keflex due to pulling out IVs -treat through 1/7    Vomiting - resolved Diarrhea - resolved  Likely 2/2 Covid Denies abdominal pain  Received 1.5L of IVF in ED Anti-emetics prn Imodium prn   Hyperkalemia: Resolved.    CLL, stable Follows with Dr. heme/onc Outpatient follow up   AKI, resolved Hold ACE, ARB, HCTZ Monitor Avoid nephrotoxic agents as able   Essential hypertension, soft bps CAD Continue toprol with hold parameters, ASA, statin Hold losartan, lisinopril, HCTZ   Dementia with sundowning inpatient Lives alone Continue aricept Daughter is DPOA   Anxiety Continue home zoloft    Diet:  Heart Healthy VTE Prophylaxis:  Lovenox SubQ Code status: DNR/ DNI    Plan to discharge to subacute rehab on 01/05/2022 if oxygen needs stabilized           Subjective    SUBJECTIVE: Patient has needed between 4 and 6 L of oxygen overnight.  Worse with activity.  Worse with sleep.  She was very sleepy this a.m..  She does open eyes and communicate, but quickly falls back asleep.  Blood pressure soft.  Afebrile.   Review of Systems Unable to perform ROS: mental status change          Objective    OBJECTIVE: BP (!) 105/42  | Pulse 81  | Temp 37.1 °C (Oral)  | Resp 16  | Ht 1.626 m  | Wt 67.8 kg  | SpO2 93%  | BMI 25.66 kg/m²  FIO2 (%): 45 % Physical Exam Constitutional:      Appearance: She is ill-appearing.     Comments: Sleepy, but arouses to voice.  Quickly falls back asleep.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.