Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Spinal X-ray abnormal, Spinal disorder, Tachycardia, Type 2 diabetes mellitus
Clinical narrative: Hospitalized (1.3.22 - still admitted currently); COVID-19 positive (1.3.22); Fully vaccinated -pfizer x2 H&P: History and Physical HOSPITALIST                                            Chief complaint Fall and weakness.   Problem List Principal Problem:   COVID-19 Active Problems:   COPD (chronic obstructive pulmonary disease)    Chronic kidney disease (CKD), stage III (moderate)    CAD (coronary artery disease)   Diabetes mellitus, type II    Hypertension   Chronic respiratory failure with hypoxia    Fall from ground level   Hyperlipidemia   Hypothyroidism   OSA treated with BiPAP     Assessment and Plan Medical Decision Making   This is an 84 years old lady who was presented to the emergency department because of generalized weakness and fall.  She has been complaining of intermittent confusion also in the last week.  She was found to have COVID-19 infection without evidence of pneumonia on the chest x-ray.  She does not have hypoxia but the patient has history of asthma and chronic obstructive pulmonary disease and uses home O2 overnight only 1 liter/minute nasal cannula.   1. Acute kidney injury.  Present on admission.  Related to poor oral intake  and using of Lasix at home.  I am holding nephrotoxic medications.  Because of the patient COVID infection, will avoid giving IV fluid for now and wait for labs in the morning.   2. COVID-19 infection.  Present on admission.  The patient does not have any changes in the chronic pattern of her breathing, no hypoxia.  As baseline she uses 1 L per minute oxygen nasal cannula overnight only.  Chest x-ray does not show any acute cardiopulmonary process.  The patient has no hypoxia.  She denies headaches, sore throat, and coughing.  No plan to give steroid for now.  Will recheck labs in the morning.  Including CRP and D-dimer.  We will put the patient on Lovenox for DVT prophylaxis.   3. Chronic obstructive pulmonary disease.  No bronchospasm or chronic obstructive pulmonary disease exacerbation.  Will continue home medications.  No need to give oral or IV steroid.   4. Diabetes mellitus type 2. The patient does not take any medications at home.  We will put the patient on 24 hour corrective insulin.   5. Hypertension.  Blood pressure is stable and controlled.  Will continue Cardizem and metoprolol.  I am holding Lasix because of the acute kidney injury.   6. DVT prophylaxis with Lovenox subcutaneous.   7. Protonix for GI prophylaxis.   9. Code status.  Because of the patient intermittent confusion, she is on full code by default for now.   The patient has intermittent confusion and slow mentation but I try to explain her conditions.  This is a virtual admission, history and physical, inpatient status.    History of Present Illness History and physical obtained using virtual technology with the assistance of the bedside nurse.   Pt. is a 84 y.o. female  who presents to hospital with fall and generalized weakness. The patient is known to have history of multiple comorbidities including anxiety, asthma, GERD, chronic obstructive pulmonary disease, diabetes mellitus type 2, hypertension, and obstructive sleep apnea.  The patient is a poor historian and the informations about her were taken from the emergency department staff physician, documentations, and bedside nursing staff.  The patient has slow mentation and confusion at times.  In the last week, the patient has not been feeling well and experiencing progressive decline of strength and her generalized weakness and fatigue.  Recently the patient had a mechanical fall, almost a week ago, and she has been experiencing right hip pain and lower back pain since then.  She did not lose consciousness no had a head trauma.  The patient denies chest pain, abdominal pain, nausea, vomiting.  She told me that she has some difficulty breathing which is chronic likely.  The patient has home O2 1 L nasal cannula oxygen supplement at night.  Her family has been experiencing cold symptoms.  At the emergency department, the patient was found to have evidence of acute kidney injury with creatinine 1.3, baseline creatinine 0.9.  Her appetite has been declining lately.  The patient PCR rapid COVID-19 test came back positive.  The patient chest x-ray did not show any evidence of acute cardiopulmonary process.  Regarding her fall, the patient CT scan of the cervical spine and CT scan of the head without contrast where unremarkable for any evidence of fracture or acute intracranial process.  The patient right hip x-ray did not show any fracture.  However her lumbar spine x-ray mild L2 superior endplate height loss which is a new comparing to the prior study in 2018. The patient is being admitted to the hospital for further evaluation treatment. Review of Systems Review of Systems Constitutional:  Positive for activity change (Because of generalized weakness.), appetite change ( decreased appetite.) and fatigue. Negative for fever.  HENT: Negative for sore throat and hoarse voice.  Respiratory:  Positive for shortness of breath (  Mild difficulty breathing.). Negative for chest tightness.   Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, diarrhea, rectal bleeding and blood in stool.  Genitourinary:  Negative for hematuria.  Musculoskeletal:  Positive for back pain (  Chronic lower back pain.), gait problem (  Baseline using a walker to ambulate.) and falls (  Mechanical fall.). Negative for neck pain and edema.  Psychiatric/Behavioral:  Negative for hyperactivity.       Slow mentation and confusion at time..      Objective BP 117/66  | Pulse 92  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.397 m  | Wt 58 kg  | SpO2 94%  | BMI 29.72 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is in acute distress.     Appearance: She is ill-appearing. She is not toxic-appearing.  Cardiovascular:     Rate and Rhythm: Regular rhythm.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Respiratory distress (Mild.) present.     Breath sounds: Rales (  Sporadic.) present. No wheezing.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    Coloration: Skin is not jaundiced.  Neurological:     Mental Status: She is alert. She is confused.     Motor: Weakness present.  Psychiatric:        Behavior: Behavior is slowed.   1/6/22 progress note: CHIEF COMPLAINT: COVID-19   Assessment/Plan    ASSESSMENT / PLAN:   1. COVID-19 viral pneumonia 2. COPD 3. Chronic hypoxia -Remains on baseline  -no indication for Decadron at this time -Continue home bronchodilators; prn nebs   4. Stroke-like symptoms -Stroke code called on 1/522; CTH/CTA head and neck/CTP reviewed. MRI brain w/o acute ischemia. Echo EF 72% -Discussed with stroke neurology; will obtain virtual visit consult -DAPT x 30 days; statin   5. Benign essential HTN -bp well controlled on Cardizem and Metoprolol   6. DM2 -monitor poc glucose checks, SSI as needed to maintain euglycemia   7. Generalized weakness -PT/OT input appreciated -SLP pending -Likely need SAR   8. CKD III -stable; avoid nephrotoxins and dose adjust medications    9. Mild LFT elevation -monitor   10. Hypothyroidism -continue levothyroxine; tsh wnl   11. UTI -continue Rocephin; cultures NGTD    per discern         Subjective    SUBJECTIVE: No new issues noted. Patient said she still feels weak. No chest pain. Afebrile.    Review of Systems  As per the HPI       Objective    OBJECTIVE: BP 133/74  | Pulse 92  | Temp 36.9 °C (Oral)  | Resp 22  | Ht 1.397 m  | Wt 60.3 kg  | SpO2 93%  | BMI 30.90 kg/m²    Physical Exam  General: NAD, non-toxic appearing but generally unwell appearing Eyes: EOM-I no scleral icterus HENT: NCAT;  CV: Slightly tachycardic; regular rhythm Lungs: non-labored respirations, decreased breath sounds but no WRR Abd: soft/nt/nd Ext: no joint swelling or TTP Neuro: flattened nasolabial folds, slumping in bed, no ataxia, sensory intact Psych: flat affect