Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Fibrin D dimer, Haematocrit normal
Clinical narrative: Hospitalized (12.11.21 - still admitted currently); COVID-19 positive (12.11.21); Fully vaccinated -pfizer x2  H&P: History and Physical     Date of Admission: 12/11/2021, Hospital Day: 1   History & Physical   CHIEF COMPLAINT: Pneumonia due to COVID-19 virus   Assessment/Plan    ASSESSMENT/PLAN: Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   DM2 (diabetes mellitus, type 2)    Essential hypertension   Sepsis Pneumonia due to COVID 19 Possible component of bacterial CAP - Vaccinated patient - received 2 doses and booster eligible in Nov - Procalcitonin less helpful in AKI at 0.30 in setting of leukocytosis, however will start treatment with abx as profoundly hypoxic in vaccinated patient - Azithro/Rocephin  - Addendum: Noted QTc 500. Will change Azithro to doxy - CXR with patchy peripheral airspace opacities - Tested positive in ER 12/11.  - Symptom onset quite unclear; pt limited historian. He reports 7 days however would use 5 days to be more conservative - Started on Decadron in ER 12/21. Cont for 10 days.  - Hold on Remdesivir given current renal function. If GFR improves to >30, would consider giving. - Supplemental O2, wean as able.   - Supportive Care with PRN anti-emetics, anti-tussives, anti-pyretics. - Prone PRN - Trend CRP and check baseline ddimer. Daily CBC/CMP - Wean O2 as able.   Toxic metabolic encephalopathy - Friend tells me he is is a little "slow to respond/answer" at baseline - No focal deficits. Is A&Ox4 but slightly confused on situation.    DMII with hyperglycemia - Anticipate steroid induced hyperglycemia as well - Goal glucose < 180 while inpatient.  - Hold any oral hyperglycemic medications (glipizide a1c 7.0% in August). - Start Lantus 5 units and moderate scale. Titrate PRN   AKI on CKD III - Baseline Cr 1.7-1.8 - Avoid nephrotoxic medications as able. Avoid NSAIDS. Renal dosing of medications - Hold home ACEi   HTN - Cont Metoprolol 25mg BID - Hold Lisinopril 40   H/o SDH after fall  - Occurred 2015   DVT ppx - lovenox subq   Full code - I discussed code status with patient and he reports full code.    Of note, patient states he does not have a spouse, children or living brothers/sisters. He tells me he does have a cousin, however reports he would want his friend to be his DPOA if he were unable to make his medical decisions. He was able to report back to me the role of a DPOA, and I feel he is currently capable of appointing one. I was able to reach his friend, and she tells me she is the  Trustee of his step-father's trust (pays patient's bills). Friend tells me she has told patient that he needs to find someone to be his medical POA as she cannot because it would be conflict of interest. She tells me patient went to college but never held a job. She describes him as socially awkward. He has a group of friends that he plays Dungeons and Dragons and involved in church. She says he has a cousin who may be willing to be DPOA. Appreciate MSW/NCM with this situation.   Addendum 2030: Noted DDimer came back at 30,280. Due to current renal function, unable to send for CTA chest. Check doppler US upper and lower extremities and start empirically treat with heparin gtt for now.      Subjective    HISTORY OF PRESENT ILLNESS: a 69 y.o. male with history of HTN, DM2, traumatic who presents to the ER with increasing fatigue, weakness, and shortness of breath. Patient limited historian at times, but says he may have been exposed to COVID earlier last week and started to feel unwell over the last 5-7 days. Per ER reports, a neighbor went to check on him and found him confused so brought him to the ER. In the ER, he had increased work of breathing. O2 sats were 86% on RA however O2 requirements increased to use of NRB. COVID19+. Patient vaccinated with Pfizer, not yet boosted. He reports nonproductive cough and shortness of breath. No wheezing, chest pain, leg pain or leg swelling. +subjective fevers at home. No abd pain, nausea, vomiting, diarrhea. CXR showed patchy peripheral airspace opacities. He was given Decadron and admitted for further management of acute hypoxic resp failure due to COVID pneumonia.    Medical History Past Medical History: Diagnosis Date ? Subdural hematoma   ? SVT (supraventricular tachycardia)      Past Surgical History Past Surgical History: Procedure Laterality Date ? HX ANKLE REPAIR       left ? HX BRAIN SURGERY   4/2/15   bur holes ? HX SHOULDER SURGERY       right     Prescriptions Prior to Admission (Not in a hospital admission)   Allergies Allergen Reactions ? Hay Fever   ? Sulfa Drugs     Social History     Socioeconomic History ? Marital status: Single     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Not on file Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Not on file Substance and Sexual Activity ? Alcohol use: Not on file ? Drug use: Not on file ? Sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative ? Not on file    Social Determinants of Health    Financial Resource Strain: Not on file Food Insecurity: Not on file Transportation Needs: Not on file Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Housing Stability: Not on file    Family History Family History Family history unknown: Yes    Review of Systems Constitutional:  Positive for activity change, fatigue and fever.  HENT: Positive for congestion.  Respiratory:  Positive for shortness of breath. Negative for wheezing.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for nausea, vomiting and abdominal pain.  Genitourinary:  Negative for difficulty urinating.  Neurological:  Negative for dizziness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Positive for sleep disturbance.  Skin:  Negative for rash.          Objective    OBJECTIVE: BP 130/82  | Pulse 98  | Temp 36.5 °C (Oral)  | Resp 23  | Wt 91.6 kg  | SpO2 93%  | BMI 27.39 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Course breath sounds bilaterally, wearing NRB Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No swelling.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.     Comments: While oriented x3, confused on situation  Psychiatric:     Comments: Flat affect   12/20/21 progress note:   CHIEF COMPLAINT: Pneumonia due to COVID-19 virus   Assessment/Plan    ASSESSMENT / PLAN:   Acute hypoxic respiratory failure Sepsis present  on admission COVID-19 pneumonia Bacterial pneumonia Vaccinated Positive test 12/11, symptom onset 7 days prior to admission chest x-ray showing patch peripheral airspace disease  Rocephin and doxycycline completed 5 days  Decadron x10 days Not given remdesivir due to current renal function   Right lower extremity DVT Possible pulmonary emboli Transitioned to Lovenox due to Heparin shortage  Plan to switch to Xarelto close to discharge    Hyperkalemia  Received one dose of kayexalate  K level trending down      Toxic metabolic encephalopathy resolved   Type 2 diabetes with hyperglycemia likely steroid related Lantus 15 units and moderate sliding scale   Acute kidney injury resolved CKD stage 3 Baseline creatinine 1.7-1.8   Urinary retention US renal complex cyst L kidney, consider CT renal mass protocol in nonemergent visit vs repeat US in 3 months UA Urology consult: recommend intermittent straight cath, if PVR routinely at > 400 cc on discharge, recommend foley placement and outpatient urology follow up     Hypertension Metoprolol Hold Lisinopril   History of subdural hematoma following a fall   DVT prophylaxis Lovenox   Full code     SUBJECTIVE: Patient was seen and examined  He took himself off high flow and was saturation in mid 90s on 3 liters NC this morning , while he was walking to the rest room with OT , there was an incident of patient collapsing while walking back to his bed , patient felt SOB and denied palpitations or chest pain , nursing staff report cyanosis . Patient is currently back on high flow NC    Review of Systems       Objective    OBJECTIVE: BP 92/67  | Pulse 103  | Temp 36.5 °C (Oral)  | Resp 16  | Ht 1.854 m  | Wt 85.8 kg  | SpO2 96%  | BMI 24.96 kg/m²  FIO2 (%): 50 % Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is not ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal. No congestion.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: No oropharyngeal exudate.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Diminished breath sounds at the bases Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No swelling or tenderness. Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.     Deep Tendon Reflexes: Reflexes are normal and symmetric.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Judgment: Judgment normal.