Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Gait disturbance, Gastrointestinal wall thickening, Hepatic lesion, Hypertension
Clinical narrative: Hospitalized (4.26.22 - 4.29.22); COVID-19 positive (4.23.22-per reports of home test); Fully vaccinated -J&J x1 d/c summary:DISCHARGE SUMMARY   BRIEF OVERVIEW Admission Date: 4/26/2022 Discharge Date: 4/29/2022 Active Hospital Problems   ? Weight loss, unintentional 04/28/2022 Yes ? Contact with or exposure to mold 04/28/2022 Yes ? COVID-19 04/26/2022 Yes ? Nausea and vomiting 04/26/2022 Yes ? Generalized weakness 04/26/2022 Yes ? Elevated blood pressure reading 04/26/2022 Yes   Resolved Hospital Problems No resolved problems to display DISCHARGE DISPOSITION: Home with services - HHA, Occupational therapy and Physical therapy DETAILS OF HOSPITAL STAY PRESENTING PROBLEM: Weakness  Intractable vomiting with nausea, unspecified vomiting type  COVID-19 virus infection COVID-19  HOSPITAL COURSE: Patient is a 86 y.o. female who presented 4/26/22 with nausea and weakness.  She has a pertinent medical history for vertigo. She states that on 4/21 she developed a sore throat and the following day developed congestion, weakness, and fatigue. She got a home COVID test on 4/23 that was positive.  She contacted her PCP on 04/25 who prescribed her Paxlovid.  She took 1 dose the evening of 4/25 and awoke overnight feeling nauseous and having dry heaves.  Throughout the day on 04/26 she continued to feel very weak, fatigued, and nauseous with a very poor appetite.   In the ER, she was found to be hypertensive as well as feeling weak and unsteady while attempting to ambulate in the ER.  Her lab work was relatively unremarkable and a repeat COVID-19 test came back positive.  She was given Zofran and IV fluids which improved the patient's symptoms.  Given the patient's persistent nausea and weakness, she was admitted to the hospitalist service for ongoing management evaluation of COVID-19 and weakness.    She was provided IV fluids and antiemetics.  She was seen by Physical therapy and Occupational therapy.  PT/OT recommendation were for home disposition with home health, assist, PT with family assistance as needed.  Medical team/nursing team had multiple discussions with the family regarding safe disposition for the patient.  Family did voice concern the patient has been losing weight and has been constipated.  A CT abdomen and pelvis was performed, which showed evidence of segmental bowel thickening in the sigmoid colon.  There was also a hypodense lesion in the liver of indeterminate etiology.  These findings were discussed with the patient and family members.  She will need an outpatient colonoscopy as well as MRI of the liver.  The patient case was discussed with her primary care physician.   It was established that the patient would return home with home assistance.  Care management/social work assessed the patient.  She is able to afford medications, food and housing without difficulty.  PT/OT assessed and recommend home PT/OT; patient in agreement.  Pure HC accepted for home PT/OT; requested close follow up for any further home needs. first home visit will be 5/2 due to capacity.  She was discharged on 04/29/2022 in good condition, with follow-up with her PCP for colonoscopy/MRI    BP 116/59  | Pulse 57  | Temp 36.7 °C (Oral)  | Resp 18  | Ht 1.575 m  | Wt 54.6 kg  | SpO2 100%  | BMI 22.00 kg/m²    Physical Exam Constitutional:    General: She is not in acute distress.    Appearance: She is well-developed.  Eyes:    Pupils: Pupils are equal, round, and reactive to light.  Neck:    Vascular: No JVD.  Cardiovascular:  Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.   No friction rub. No gallop.  Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:    General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no rebound.  Musculoskeletal:       General: No deformity or edema. Normal range of motion.     Cervical back: Normal range of motion.  Skin:   Findings: No rash.  Neurological:    Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:       Mood and Affect: Mood and affect normal.   4/26/22 H&P:CHIEF COMPLAINT: Nausea and vomiting  ASSESSMENT/PLAN: COVID-19 Assessment & Plan Reports symptoms started 4/21 and took home COVID test that was positive 4/23 COVID positive in the ER today 4/26 Was prescribed Paxlovid as outpatient and first dose was 4/25. Will not resume. Currently on room air Hold off on starting remdesivir or decadron Continues with nausea, vomiting, dry heaves Morning CBC, CMP, CRP, D-Dimer   * Nausea and vomiting Assessment & Plan Suspect secondary to Paxlovid Continue normal saline at 100 Clear liquid diet and advance as tolerated PRN zofran   Elevated blood pressure reading Assessment & Plan Suspect secondary as side effect of Paxlovid PRN hydralazine for SBP >180     Generalized weakness Assessment & Plan Suspect secondary to COVID-19 and dehydration PT/OT consult Does live home alone May need discharge planning assistance HISTORY OF PRESENT ILLNESS: A patient s a 86 y.o. female who presents today with nausea and weakness.  She has a pertinent medical history for vertigo. She states that on 4/21 she developed a sore throat and the following day developed congestion, weakness, and fatigue. She to go home COVID test on 4/23 that was positive.  She contacted her PCP on 04/25 who prescribed her Paxlovid.  She took 1 dose the evening of 4/25 and awoke overnight feeling nauseous and having dry heaves.  Throughout the day on 04/26 she continued to feel very weak, fatigued, and nauseous with a very poor appetite.  Due to this she presented to the ER.  She currently denies fever, chills, shortness of breath, chest pain, abdominal pain, leg pains.  She does endorse mild occasional dizziness, and nausea however is enquiring about eating tonight.  She states that prior to taking the Paxlovid she was not experiencing nausea, dry heaves, or vomiting. She is vaccinated with one dose of J&J vaccine.   In the ER, she was found to be hypertensive as well as feeling weak and unsteady while attempting to ambulate in the ER.  Her lab work was relatively unremarkable and a repeat COVID-19 test came back positive.  She was given Zofran and IV fluids which improved the patient's symptoms.  Given the patient's persistent nausea and weakness, she will be admitted to the hospitalist service for ongoing management evaluation of COVID-19 and weakness.  The plan will be to continue IV fluids overnight and repeat labs in the morning.  I will also have PT and OT evaluate the patient tomorrow with recommendations for discharge.  The patient does live home alone and she may benefit from discharge planning.  I updated the patient and daughter on the plan of care all questions and concerns were addressed to patient's satisfaction.   I discussed patient's code status with her in detail.  She states that she would want CPR/chest compressions if her heart were to stop.  However she would not want intubation with mechanical ventilation.  She will be made a partial code with DNI at this time.  Review of Systems Constitutional:  Positive for fatigue. Negative for chills.  HENT: Positive for sore throat. Negative for congestion.  Respiratory:  Negative for cough, wheezing and shortness of breath.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Positive for nausea and vomiting. Negative for abdominal pain, constipation, diarrhea and rectal bleeding.  Genitourinary:  Negative for difficulty urinating, urinary incontinence, dysuria and urgency.  Musculoskeletal:  Negative for back pain, muscle pain, falls and edema.  Neurological:  Positive for dizziness and weakness. Negative for headaches, light-headedness and numbness/tingling.  Endo/Heme/Allergy:  Negative for adenopathy.  Psychiatric/Behavioral:  Negative for depression and anxiety.   OBJECTIVE: BP 156/69  | Pulse 77  | Temp 36.6 °C (Oral)  | Resp 18  | Ht 1.651 m  | Wt 43.1 kg  | SpO2 100%  | BMI 15.83 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is underweight. She is not ill-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Abdominal:     General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.     Motor: Tremor present.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.