Age: 86.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Cardiac telemetry, Chest X-ray normal, Chronic kidney disease, Chronic left ventricular failure
Clinical narrative: DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia [R09.02] Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 [U07.1] Encephalopathy due to COVID-19 virus [U07.1, G93.49] HOSPITAL COURSE: COVID-19 virus detected; Assessment & Plan Fully vaccinated patient Exposed to COVID + person on 8/20/21; Symptoms developed 8/21/21 including sore throat, cough; COVID + on 8/23/21; CXR negative for acute infiltrate; Transient hypoxia with standing to 87% and nml at rest; Will admit for observation and evaluate other etiologies of transient hypoxia (bacterial infection, bronchitis, CHF exacerbation, DVT/PE) In the interim, treat for COVID 19 including monoclonal antibody infusion, add remdesivir, decadron IV, and other meds for symptom relief. Home oxygen evaluation in am.  08/24/2021 Suspect component of COVID induced acute encephalopathy, metabolic type, additional precipitating factors include hypoxia resulting from acute respiratory failure, steroid use, underlying dementia; Diabetes mellitus with neuropathy (HCC); Assessment & Plan; A1C of 6.2 indicates good outpatient control; Continue statin. Will monitor diascans with basal bolus coverage as patient is on IV steroids. Aortic stenosis; Assessment & Plan Moderate to severe AS - avoid overdiuresis; Continue afterload reduction; Chronic kidney disease, stage 3; Assessment & Plan; Stable renal function at this time.  Will monitor daily labs with COVID positivity; Atrial fibrillation (HCC) Assessment & Plan; Rate control with Metoprolol XL and anticoagulate with Eliquis; Monitor telemetry; Maintain K > 4, Mg > 2 and appropriate oxygenation; Benign essential hypertension Assessment & Plan; Continue home medications and titrate prn; BPH (benign prostatic hyperplasia) Assessment & Plan; Continue home meds and monitor for urinary retention. Chronic combined systolic and diastolic congestive heart failure (HCC)Assessment & Plan; Appears euvolemic at this time.  Patient unable to tell me his dry weight due to underlying dementia.  Will monitor daily weights and I/O's and continue home CHF regimen. Sleep apnea; Assessment & Plan; Monitor for nocturnal hypoxia and try to speak with wife about if patient is on CPAP. Stasis edema of both lower extremities; Assessment & Plan; Continue support hose and elevation while sitting. D dimer and check venous dopplers if elevated; Obesity; Assessment & Plan; With associated comorbid illnesses + RF for COVID pneumonia with DM,CHF. Hypoxia; Assessment & Plan; 87% on RA w/ transfer Will titrate Fi02 to maintain Sa02 > 88% Prone as needed. Likely not COVID 19 pneumonia with negative CXR in vaccinated individual, but will continue to monitor and treat for this and explore other etiologies.  (This assessment was present on admission, however on a subsequent CXR and based on subsequent clinical evaluation COVID Pneumonia was demonstrated) Code status is full until I can reach his wife. Late onset Alzheimer's disease without behavioral disturbance (HCC) Assessment & Plan; Continue home meds, avoid sensory and sleep deprivation and anticholinergic medications. Update 08/25/2021; The patient was admit to the hospital with COVID infection, early signs of pneumonia on the chest x-ray, given steroids, DVT prophylaxis, aerosols, improved, remained on room air, will be discharged home with self quarantine for a total of 14 days from the onset of symptoms. Confusional episodes during the hospitalization related to a combination of factors including dementia, steroid medication, being in an unfamiliar environment/hospital delirium, COVID encephalopathy. The patient will do better at home, his son was also hospitalized at the same time, son was released therefore the patient can be released as well since son is the caregiver. Prescription for short course of prednisone for 5 days, a Z-Pak, Mucinex, recommendation for over-the-counter vitamin-C, zinc, vitamin-D.  Avoidance of situations that may promote falling.