Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Acquired diaphragmatic eventration, Acute kidney injury, Anion gap decreased, Anticoagulant therapy, Arteriosclerosis
Clinical narrative: COVID + diagnosis & hospitalization of previously vaccinated patient (x2 - 2/26/21 & 3/26/21)  HISTORY OF PRESENT ILLNESS: Patient is a 73-year-old male with past medical history of hypertension.     The morning of 5/29 patient presented to the ER with complaints of loss of appetite, cough, and fatigue.  He was found to be COVID-19 positive workup was benign patient was ambulated and did not go lower than 93% oxygen on room air and was discharged home Patient returned late evening of 529 due to continued nausea, fall from standing position due to syncope after getting up out of bed, and a laceration above his right eye. Patient states his symptoms started approximately 1 week ago after having a tubal he noticed decreased appetite and not wanting to drink much.  He thought this was just due to the dental surgery.  However this continued into body aches, fatigue, dry cough, dry mouth.  ER course:  Temp 38.2°, heart rate 74, blood pressure 134/55, respiratory rate 24, oxygenation 91% on room air with ambulation patient dropped to 88% on room air but stabilizes with rest. COVID-19 positive CT head and spine were obtained and showed no evidence of any acute injury or intracranial process.  Chest x-ray was obtained and showed bilateral streaky infiltrates suspicious for bronchopneumonia. EKG is normal sinus rhythm with no ST changes, QTC 474 Complete blood count shows absolute lymphopenia and hemoglobin 13.3, platelets 101 Glucose 176, creatinine 1.45 GFR 48   No Known Allergies Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider Cholecalciferol (VITAMIN D3) 2000 UNITS TABS take  by mouth Daily.       Historical Provider hydrochlorothiazide (HYDRODIURIL) 25 MG tablet take 25 mg by mouth Daily. for diuretic       Historical Provider metoprolol tartrate (LOPRESSOR) 50 MG tablet take 50 mg by mouth Daily.       Historical Provider Misc Natural Products (OSTEO BI-FLEX JOINT SHIELD PO) take  by mouth Daily.       Historical Provider Multiple Vitamins-Minerals (MULTIVITAMIN PO) take  by mouth Daily.       Historical Provider Omega-3 Fatty Acids (FISH OIL PO) take 1,200 mg by mouth Daily.       Historical Provider ondansetron (ZOFRAN-ODT) 4 MG disintegrating tablet Take 1 tablet by mouth every 8 hours as needed for Nausea. 5/29/21      MD vitamin B-12 (CYANOCOBALAMIN) 1000 MCG tablet take 1,000 mcg by mouth Daily.       Historical Provider   Medical History Past Medical History: Diagnosis Date ? Hyperlipidemia   ? Hypertension    Past Surgical History Past Surgical History: Procedure Laterality Date ? HX COLONOSCOPY   1-9-14   Dr.  ? HX HAND SURGERY   2011   thumb ? HX NASAL SURGERY   2008  Social History   Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used Substance Use Topics ? Alcohol use: No ? Drug use: Not on file    Family History History reviewed. No pertinent family history.  Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for chills, diaphoresis and fever.  HENT: Negative for congestion, rhinorrhea and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough. Negative for shortness of breath.   Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Positive for nausea and diarrhea. Negative for vomiting and abdominal pain.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Positive for muscle pain and falls.  Neurological:  Positive for headaches and weakness. Negative for dizziness and light-headedness.  Skin:  Negative for rash.   OBJECTIVE: BP (!) 170/48  | Pulse 82  | Temp 38.2 °C (Oral)  | Resp 22  | Ht 1.753 m  | Wt 77.3 kg  | SpO2 94%  | BMI 25.18 kg/m²    Room air   Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance.     Comments: Appears fatigued  HENT:     Mouth/Throat:     Mouth: Mucous membranes are dry.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses:          Dorsalis pedis pulses are 2+ on the right side and 2+ on the left side.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are increased. There is no distension.     Palpations: Abdomen is soft.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.     Comments: Moving all 4 extremities spontaneously  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and easily aroused.     Comments: Patient is oriented but forgetful and poor historian  Psychiatric:        Attention and Perception: Attention normal.        Mood and Affect: Affect is flat.        Speech: Speech normal.        Behavior: Behavior is cooperative.  _________________________    ASSESSMENT/PLAN: COVID-19 Pneumonia with intermittent hypoxia - admit inpatient - chest xray shows bilateral streaky infiltrates - days of symptoms #7 - tested positive 5/29 - O2 requirements: drops to 88% with activity, back to 91% with rest - start decadron 6mg PO - start Remdesiver day #1/5              *Daily renal and liver function monitoring for kidney and liver toxicity due to Remdesvir is required. - trend CMP/CBC, check D-dimer and CRP (and trend as required) - pronation as tolerated, Incentive Spirometry, keep euvolemic - continue home Vit. D 2,000 units daily - PRN Tylenol, tessalon, albuterol   Syncope Fall Laceration above right eyebrow - believe d/t #1 - CT head/spine negative - tele for now - laceration repaired via glue   AKI - potentially on top of CKD, last Creat over a year ago was 1.23 - on admission creat 1.45 - give a 500ml NS bolus - hold home hctz - trend CMP   HTN - continue home Metoprolol 50mg daily - hold hctz d/t AKI   Diet: Adult general Code status: Full VTE prophylaxis: Heparin subq   6/1/2021 - Assessment/Plan COVID-19 Pneumonia - chest xray shows bilateral streaky infiltrates in right mid lung and mid/LLL no consolidations per read  - days of symptoms #7 on admission  - tested positive 5/29 - stable on room air - Continue decadron 6mg PO day 3/10 - Continue Remdesiver day #3/5 - trend CMP/CBC, check D-dimer and CRP  - pronation as tolerated, Incentive Spirometry, keep euvolemic - continue home Vit. D 2,000 units daily - PRN Tylenol, tessalon, albuterol   Syncope Fall Laceration above right eyebrow - believe d/t #1 - CT head/spine negative - does not report any repeat symptoms will DC tele - laceration repaired via glue    HTN - continue home Metoprolol 50mg daily - hold hctz in the setting of acute illness   AKI (resolved)   Diet: Adult general Code status: Full VTE prophylaxis: Heparin subq Dispo:  Patient is stable but would likely benefit from an additional day of steroids, remdesivir, and observation anticipate discharge tomorrow.