Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Abdominal distension, Acute respiratory failure, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy
Clinical narrative: Hospitalized (12.23.21 - 12.26.21); COVID-19 positive (12.23.21); Fully vaccinated -moderna x2 d/c summary: Discharge Summary MD (Physician) ? ? General Medicine BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: DO Admission Date: 12/23/2021 Discharge Date: 12/26/2021      Active Hospital Problems   Diagnosis Date Noted POA ? COVID 12/23/2021 Unknown Discharge Disposition:  home health care svc    Active Issues Requiring Follow-up:   - Recommend follow-up your primary care physician to ensure continued clinical improvement.  - Recommend continue working with home healthcare services to improve strengthening of the lower extremities.   - Recommend continued use of as-needed oxygen at rest or with activity.  Is recommended patient continue to isolate, wear masks for total of 10 days from symptom onset.   Pending Labs    Order Current Status   Peripheral Blood Culture Preliminary result   Peripheral Blood Culture Preliminary result     DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia [R09.02] Generalized weakness [R53.1] COVID-19 virus infection [U07.1] COVID [U07.1]   HOSPITAL COURSE: 84-year-old man with history of chronic atrial fibrillation on Coumadin, nonischemic cardiomyopathy, chronic obstructive pulmonary disease, CKD who was recently admitted for GBS bacteremia and have completed antibiotics course in SAR.  He has been home for 2 weeks. He has been weak since returning home.  Patient did have a fall 2 weeks ago upon returning home, where he reports his legs gave out while walking with his walker and he landed on his buttock and right side.  He has had pain in the right posterior ribs and right shoulder.  He denies any head injury or loss of consciousness.  At that time, he was able to stand with assistance after the fall.  Patient had a repeat fall today walking with his walker.  He states his legs again gave out and he landed on his buttock.  He again denies any head injury or loss of consciousness. The patient is fully vaccinated with Moderna but overdue for booster. Patient's son is COVID-19 positive, and is in quarantine in the front of the house.    In the ED, he tested positive for COVID. Desats 87% with activity. CXR negative. He received Decadron and 1 L of Saline due to low po intake. Unfortunately his O2 needs increased to 6L upon arrival at BL   While at Facility the patient continued to improve.  Required no more than 4 L nasal cannula eventually requiring only 2 L at rest and with activity.  Patient remained afebrile normotensive and continue to hemodynamically improved.  Recommend patient follow up with his PCM within 3-5 days of discharge. CONSULTS / RECOMMENDATION:   Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:   Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 139/72  | Pulse 97  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.753 m  | Wt 128 kg  | SpO2 93% Comment: ambulating | BMI 41.67 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: He is well-developed.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rhonchi.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert.  H&P: CHIEF COMPLAINT: COVID     Assessment/Plan    ASSESSMENT / PLAN:   Acute respiratory failure with hypoxemia due to COVID Pneumonia  Severe COVID Pneumonia Fully vaccinated with Moderna but have not received Booster yet  Exposed to COVID Positive son Was on RA and only desats with Activity in the ED but Now on 6L of O2 S/p 1 L of IVF I suspect Pulmonary edema may play a role in his sudden increased in O2 needs Will repeat another CXR now  Will give 40 of Lasix IV NOW  Continue Decadron 6 mg daily  Unclear how long he has been symptomatic and with is underlying CkD, will hold off Remdesivir  Continue Aggressive pulmonary Hygiene, prone ventilation  Isolation per protocol    Recurrent Falls No syncope or head trauma CT Thorax without contrast no acute trauma in the chest  Likely due to generalized weakness from COVID PT/OT  Check Orthostat when able   Recent admit for GBS bacteremia 11/15/2021 Completed Abx course at Rehab   CKD 3a Cr close to baseline Will strive to avoid nephrotoxic agents and dose meds per GFR   Chronic A fib on Coumadin  Mitral and Aortic stenosis  INR therapeutic Daily INR  Continue home coumadin dosing   DM II  Will start lantus and sliding scale insulin  On High dose Toujeo and sliding at home  Monitor POC glc per protocol Update A 1c   HLD Continue Statin    NICM without angina  Resume home Torsemide 20 mg bid  Continue Lisinopril, statin  OSA   GERD PPI   Hypothyroidism  Synthroid    HTN  Continue Lisinopril    Morbid Obesity  Will encourage weight loss  BMI of 39.56   DVT prophy on Coumadin  FULL CODE   HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old man with history of chronic atrial fibrillation on Coumadin, nonischemic cardiomyopathy, chronic obstructive pulmonary disease, CKD who was recently admitted for GBS bacteremia and have completed antibiotics course in SAR.  He has been home for 2 weeks. He has been weak since returning home.  Patient did have a fall 2 weeks ago upon returning home, where he reports his legs gave out while walking with his walker and he landed on his buttock and right side.  He has had pain in the right posterior ribs and right shoulder.  He denies any head injury or loss of consciousness.  At that time, he was able to stand with assistance after the fall.  Patient had a repeat fall today walking with his walker.  He states his legs again gave out and he landed on his buttock.  He again denies any head injury or loss of consciousness. The patient is fully vaccinated with Moderna but overdue for booster. Patient's son is COVID-19 positive, and is in quarantine in the front of the house.    In the ED, he tested positive for COVID. Desats 87% with activity. CXR negative. He received Decadron and 1 L of Saline due to low po intake. Unfortunately his O2 needs increased to 6L upon arrival at BL.   Patient Active Problem List Diagnosis ? Atrial fibrillation   ? Arthritis ? Hyperlipidemia ? Hypertension ? Type 2 diabetes mellitus with diabetic polyneuropathy, with long-term current use of insulin  ? Vitamin D deficiency ? OSA (obstructive sleep apnea) ? GERD (gastroesophageal reflux disease) ? Hypogonadism male ? Cardiomyopathy, nonischemic   ? Benign paroxysmal positional vertigo, unspecified laterality ? Osteoarthritis of spine with radiculopathy, lumbar region ? Hypothyroidism, unspecified type ? Glaucoma ? Frequent falls ? Morbid obesity   ? Chronic atrial fibrillation   ? Chronic anticoagulation ? Aortic stenosis ? Polyneuropathy ? At high risk for injury related to fall ? Cubital tunnel syndrome of both upper extremities ? Dyspnea on minimal exertion ? Mitral stenosis ? Chronic right-sided thoracic back pain ? Poor balance ? Multiple lung nodules ? Gait disturbance ? Essential hypertension ? Chronic obstructive pulmonary disease, unspecified   ? Stage 3 chronic kidney disease   ? Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene   ? Rash ? Early dry stage nonexudative age-related macular degeneration of both eyes ? Platelets decreased   ? Weakness ? Acute metabolic encephalopathy ? COVID Review of Systems Constitutional:  Positive for fatigue. Negative for chills and fever.  HENT: Negative for sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for shortness of breath. Negative for cough, wheezing, chest tightness and sputum production.   Cardiovascular:  Negative for chest pain, palpitations, leg swelling and PND.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for dysuria, polyuria and urgency.  Musculoskeletal:  Negative for back pain.  Neurological:  Negative for headaches, dizziness, light-headedness, loss of consciousness, numbness/tingling and weakness.  Endo/Heme/Allergy:  Negative for adenopathy.  Psychiatric/Behavioral:  Negative for depression.  Skin:  Negative for rash.          Objective    OBJECTIVE: BP (!) 153/106  | Pulse 128  | Temp 36.8 °C (Oral)  | Resp 28  | Wt 121.5 kg Comment: Simultaneous filing. User may not have seen previous data. | SpO2 95%  | BMI 39.56 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is in acute distress.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.     Comments: No peripheral edema and JVD Pulmonary:     Effort: Respiratory distress present.     Breath sounds: No wheezing or rales.     Comments: Diminished BS with mild accessory muscle use Chest:     Chest wall: No tenderness.  Abdominal:     General: Bowel sounds are normal. There is distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no rebound.  Musculoskeletal:        General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: Edema (1+) present.     Left lower leg: Edema (1+) present.     Comments: Bruises on the skin  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Deep Tendon Reflexes: Reflexes normal.     Comments: None focal  Psychiatric:        Mood and Affect: Mood normal.