Age: 90.0
Sex: M
Vaccine: COVID19-2
Symptoms: Cardiac telemetry abnormal, Chest X-ray abnormal, Chronic kidney disease, Condition aggravated, Decubitus ulcer
Clinical narrative: Patient is a 91 y.o. male with a PMHx significant for Parkinson's disease with dementia, CKD stage II, HTN, OSA on CPAP, insulin-dependent T2DM, BPH, and HLD who presented from SNF on 7/28/2023 with a one day history of shortness of breath and cough productive of yellow sputum. He was afebrile with WBC wnl and did not meet SIRs criteria. Was found to be Covid-19 positive on admission. He received remdesivir and steroids in the beginning with quick improvement.  Chest x-ray without signs of pneumonia.  Last remdesivir and steroids were discontinued.  His symptoms continue to improve now off oxygen. He is medically stable for discharge back to his facility.          Assessment and Plan   Acute hypoxia Respirator.  - Baseline inflammatory markers: CK = 41, D-Dimer = 0.87, Ferritin = 42, Fibrinogen = 483 on admission. -Apparently he was off O2 on Saturday but needed it back on Sunday -Repeat chest x-ray 7/30 with mild bibasilar atelectatic changes with no pneumonia noted.  Possible small effusions. -Patient received 2 doses of remdesivir, discontinued  as CXR was equivocal and puts the patient at risk of additional side effects. Steroids was also on hold -SLP evaluation rec chopped and thin liquids. He may have a component of aspiration as well. -Encourage incentive spirometry, PEP -Wean off O2. Feels well able to discharge home.    COVID-19 infection -Date of symptom onset 7/27/2023; date of positive SARS-CoV-2 test 7/28/2023. Vaccinated x3. -Patient with minimal respiratory symptoms currently.  His last vaccination with Moderna in 11/2022 -Patient with hypoxia noted, chest x-ray findings are not consistent with COVID-pneumonia. -steroids was on hold given lack of radiologic findings for COVID-19 pneumonia.  Stop remdesivir given lack of clinical data supporting use. -repeat inflammatory markers on 8/1 wnl.  -Repeated CXR on 8/1: Mild bibasilar atelectatic changes, Small bilateral pleural effusions are difficult to exclude, No edema, failure or pneumothorax noted   Dysphagia -In the setting of Parkinson's disease -SLP was consulted. Had MBS on 7/13. Recommending chopped meats and thin liquids with compensatory strategies.   AKI on CKD Stage IIresolved -Mild AKI in setting of dehydration.  Due to osmotic diuresis from hyperglycemia as well as decreased oral intake -Improved with hydration -Monitor kidney function while diuresing   Abnormal troponin -Adynamic troponin without angina or angina equivalent symptoms. -EKG with first-degree AV block   Irregular heart rhythm -Based on telemetry review most likely sinus rhythm with PACs as well as multifocal atrial tachycardia -Discussed with son-in-law Dr. given prior history of stroke, EP was consulted -EP stating no signs of atrial fibrillation, has frequent PACs and multiple morphologies.  No further work-up.   Diabetes mellitus type 2 on long-term insulin -Chronically under acceptable control A1c 8.4 most recently. -A1c 8.4 on 6/10/2023  -Home regimen Lantus, metformin, pioglitazone, Januvia -Glucose not at goal patient received 1 dose of steroids -Increase Lantus to 60 units, 1:8 prandial insulin.  And adjust as needed - Holding home Metformin, Pioglitazone, and Januvia.   Parkinson's Disease with Dementia Depression - Follows closely with neurology.  - Continue home Rivastigmine 4.5 mg BID, Sinemet 25-100 and 50-200 mg (morning and nightly doses, respectively), and Effexor 75 mg daily. AVOID use of dopaminergic agents (ie Haldol) if agitation or delirium ensues. Pressure injury -  left buttock stage 2 PI, presented on admission  - left leg wound from injury one month ago  - consulted for wound care    Microcytic anemia  - hb stable in 10-11 range. Microcytic - Possible iron-deficiency. ferritin 42 on admission  - consider iron supplement as acute infection resolved   Reduced mobility requiring device due to hemiplegia POA - 2/2 late effect of CVA  - Left hemiplegia with impaired mobility; full time power wheelchair use since 2022       - residing, will upgrade to skilled nursing level of care