Age: 91.0
Sex: M
Vaccine: COVID19
Symptoms: Mental status changes, Mitral valve incompetence, Monocyte count normal, Monocyte percentage, Myocardial ischaemia
Clinical narrative: Date of Service Jul-08-2022 1121  Date of Admission Admit Date: Jul-06-2022  Date of Discharge Date of discharge Jul-08-2022  Allergies No Known Allergies  Chief Complaint Altered mental status  Final Diagnoses Urinary tract infectious disease  Anemia  COVID-19  Pneumonia  Permanent atrial fibrillation  Rapid atrial fibrillation  Aortic valve stenosis  High troponin I level  Non-rheumatic mitral regurgitation  Chronic renal insufficiency  Acute diastolic heart failure  Procedure(s) Performed None  Lab Results Jul-08-2022 0332 Chemistry GLUCOSE  152BUN  58CREAT  1.8MDRD GFR  36NA  138K  4.2CL  106CALCIUM  8.2ALK PHOS  69CO2  21.8AST  36ALT  15AST/ALT  2.4TL PROT  7.1ALBUMIN  3.3TBILI  0.9OSMO  294.8ANION GP  14.4BUN/CRE  32.2CRP  4.50 Jul-08-2022 0332 Hematology WBC  11.0RBC  3.23HGB  7.5HCT  24.8MCV  76.8MCH  23.2MCHC  30.2RDW  17.3RDWSD  48.2PLT  311MPV  10.2AUTONEU%  91.1AUTOLYM%  3.9AUTOMON%  4.2AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  10.1AUTOLYM#  0.4AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.3IG#  0.08IG%  0.7 Jul-08-2022 0332 Serology PROCALC  0.87 Jul-07-2022 1655 Hematology HGB  6.9HCT  23.5 Imaging Results CH-chest 1V DR  07/06/2022  Impression: Bilateral interstitial thickening and ground-glass opacities in the mid and lower lungs compatible with atypical/viral pneumonia in the appropriate clinical context. Read by (name withheld)  Noncontrast CT head 07/06/2022 Impression:  1. No acute intracranial hemorrhage.   2. White matter hypodensities are nonspecific, however likely related to chronic small-vessel ischemic changes.   3. Exam quality is slightly degraded by motion. Read by (name withheld)  CH-chest 1V DR 07/06/2022 Impression:  Possible small right pneumothorax versus skin fold.  Recommend dedicated PA and lateral views or CT.  Bilateral pneumonia and-or pulmonary edema, ARDS pattern, slightly more confluent within the right mid lung from prior.  Cardiomegaly. Read by (name withheld)  Echocardiogram complete with 2D, M -mode, and Doppler examination.  07/06/2022 Conclusion:  Normal left ventricular systolic function with an LVEF> 60%.  Mild left ventricular hypertrophy ( measuring diameter 1.1 cm- 1.3 cm).  Moderate enlargement of the left atrium with LA index volumes between 42-48 cm2.  Mild mitral regurgitation.  Mild aortic stenosis (AVA> 1.5 cm2). mild tricuspid regurgitation.  The estimated peak RVSP is 31 mm Hg.  Technically difficult- patient in atrial fibrillation with rapid response.   Read by (name withheld)  CH -chest 1V DR 07/07/2022 Impression:  Continued multifocal pneumonia.   Read by (name withheld)  CH-chest 1V DR 07/08/2022 Impression: 1.  Bilateral pulmonary opacities, mildly improved in the right lung.   2. Unchanged cardiomegaly Read by (name withheld)  Functional Status* Activity of daily living - Needs assistance  Mental Status* Normal Cognition  Social History tobacco use Former Smoker, 1 Packs Per Day, Ended Jul-01-2011, Smoking Cessation No  alcohol use Beer, Former  drug use No Known Use  marital status Widowed  Health Concerns Urinary tract infectious disease  Chronic renal insufficiency  High troponin I level  Non-rheumatic mitral regurgitation  Aortic valve stenosis  Rapid atrial fibrillation  Permanent atrial fibrillation  Acute diastolic heart failure  COVID-19  Anemia  Pneumonia  Former Smoker, 1 Packs Per Day  Beer, Former  Mother Deceased  Vital Signs Jul-08-2022 1223 T 98.2 HR 91 RR 18 BP   129 / 77 O2Sat 91 Jul-08-2022 0400 HR 90 RR 20 BP   120 / 79 O2Sat 98 Jul-08-2022 0200 HR 100 RR 18 BP   132 / 62 O2Sat 98 Jul-07-2022 1619 T 97.8 Jul-07-2022 1200 T 98.5 PHYSICAL EXAM Constitutional:  Patient appears chronically ill but no acute distress.  HEENT: Atraumatic normocephalic head, PERRLA bilaterally, oral mucosa appeared moist without fissures noted in the tongue. Cardiovascular:  Irregularly irregular rhythm with normal rate, no murmurs noted on auscultation, radial pulses 2+ bilaterally, no edema noted in lower legs.      Respiratory:  Breath sounds observed bilaterally, expiratory wheezes noted without crackles, normal respiratory effort noted.   GI no abdominal tenderness nor distension, normoactive bowel sounds, no organomegaly noted.   Skin:  Skin appears dry with no new wounds or rashes.   Neuro: AOx4 , no sensation abnormalities noted in the upper extremities.   Psych:  RASS score equals 0 patient seemed agitated and anxious, without depression.   Heme:  No abnormal bruising or bleeding noted  Consultations Cardiology   Hospital Course 91-year-old male who was brought to the ER from nursing home because the nursing home staff found him unresponsive.  Patient has a past medical history of hypertension, benign prostate hypertrophy,  atrial fibrillation, anemia, constipation.  Patient has previously received blood transfusions for his chronic anemia.    Nursing home reports he received a COVID booster yesterday, and tested positive for COVID today. They report today he was not responding, his pupils were not responding, and he had diaphoretic rapid breathing.   In the ER the patient became more awake and was able to talk and converse on room air with no problems. The 1st night in the hospital patient started having chest pain and shortness of breath.  Troponin levels increased likely due to ischemic demand due to his severe anemia.  Patient was started on nitroglycerin drip and was given morphine which resolved the pain.  Patient was put on BiPAP at 30% O2 which resolved his shortness of breath and helped him sleep.    Patient was started on remdesivir and dexamethasone 6mg due to his COVID positive status.  Patient was also started on azithromycin 500 mg to help protect against bacterial COVID super infection.  after the 1st night of BiPAP patient was able to titrate down to 2 L supplemental O2 the 1st day and currently has stable O2 breathing at room air.   Patient was diagnosed with the UTI and was started on Rocephin.  Cultures reported the bacteria was Proteus sensitive to cephalexin which the patient will continue for 4 days in the outpatient setting.   Due to the patient's HTLA antibodies patient was unable to receive infusion of blood until the 2nd morning at which point he received 1 unit which brought his hemoglobin up to 6.9.  Iron studies were performed which aided in the diagnosis of iron deficiency anemia.  Patient will begin receiving supplemental iron every other day to help with anemia, which will be followed by his PCP on outpatient setting.  During patient's hospital stay he was taken off Eliquis 5 mg b.i.d. due to a fear of GI bleed.  Condition at Discharge Stable  Discharge Medications atorvastatin 20 mg tablet 1 TAB ORALLY DAILY AT BEDTIME Azithromycin Oral Tablet 250 MG 250 MG ORALLY DAILY Cephalexin Oral Capsule 500 MG 500 MG ORALLY TWICE DAILY Eliquis 5 mg tablet 1 TAB ORALLY TWICE DAILY Flomax 0.4 mg capsule 1 CAP ORALLY ONCE A DAY Iron (Ferrous Sulfate) Oral Tablet 325 (65 Fe) MG 325 MG ORALLY MON WED FRI SAT metoprolol tartrate 25 mg tablet 0.5 TAB ORALLY TWICE DAILY Miralax 17 gram/dose powder Continue taking same as home Tylenol Oral Tablet 325 MG 650 MG ORALLY AT BEDTIME Vitamin C Oral Tablet 100 MG 100 MG ORALLY ONCE A DAY Vitamin D3 25 mcg (1,000 unit) capsule 1 CAP ORALLY ONCE A DAY Discharge Disposition Transfer to nursing facility   Plan Assessment: Acute on chronic iron deficiency anemia (Hgb 6.0 on admission, 7.5 on discharge) ARDS secondary to SARS-COVID Pneumonia (likely ARDS due to chest x-ray readings) (COVID positive 7/6/22) - improving and currently requiring no supplemental oxygen. Demand ischemia likely secondary to anemia.  Urinary tract infection - Proteus sensitive to cephalosporins, on antibiotics Acute kidney infection on Chronic kidney disease (stage 3b) (Cr 1.7, BUN 36 on admission) - stable Atrial fibrillation - medically controlled Grade 3 diastolic heart failure (per echo 11/21) Essential hypertension - controlled with medications Benign prostatic hyperplasia - per history   Plan:   The patient's condition is stable at this time and will be transferred today to nursing home. We will discharge the patient on their home medications as reconciled above. We will send the patient home with cephalexin 500 mg b.i.d. 4 days, azithromycin 250 mg for 3 days,   and iron supplementation 325 mg every other day on discharge. They are to resume a cardiac diet. Resume activity as tolerated.  We recommend the patient follow up with nursing home PCP within 1 week for hospital follow-up.   We thank Dr. and his team for the assistance in caring for this patient.  The patient was evaluated by Dr. and the plan of care was discussed with this resident.      Discharge Instructions Diet cardiac  Activity as tolerated  Primary Care Provider   Electronically signed on Jul-08-2022 1435 I have seen and physically examined the patient on 7/8/22 and agree with the documentation. I have also discussed my findings and plan of care. Any changes and additional information are listed below. Electronically signed on Jul-09-2022 1010