Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bicarbonate, Blood bicarbonate decreased, Blood bilirubin decreased, Blood calcium decreased, Blood chloride decreased
Clinical narrative: ED 11/13 diarrhea/SOB - d/c home - +COVID test.  Hospitalized (11.15.21 - still admitted currently); COVID-19 positive (11.13.21); Fully vaccinate.   HISTORY OF PRESENT ILLNESS: Patient is a 82 y.o. male who presents today with fatigue and increased cough, congestion shortness of breath.  Patient also reports significant diarrhea in which he is most concerned.  Patient has a history of CVA, hypertension, coronary artery disease, CKD, and diabetes.  Patient reported 6 days of not taking his home medication and restarted today. Due to his continued feeling of fatigue and diarrhea, patient presented to ED for further care.  In the emergency department, patient was found to be hypoxic requiring 6 L nasal cannula to maintain oxygen saturation greater than 90%.  Patient was also found to have increased creatinine greater than his baseline CKD, with hypoglycemia.  Patient was given IV dextrose with resolved.  Patient also had chest x-ray which showed COVID pneumonia and CHF essentially unchanged from previous exam 2 days prior.  Patient was given 1 dose remdesivir and transferred to hospitalist service for continued care. Assessment/Plan    ASSESSMENT / PLAN:   * Acute respiratory disease due to COVID-19 virus Assessment & Plan Patient reports onset diarrhea on 11/10/2021, with continued fatigue and shortness of breath. Also, c/o fever, decreased appetite and oral intake.  Patient reports he has not taken his home medications in 5-6 days.    Patient remained on 100% high flow nasal cannula throughout the night with p.r.n. non-rebreather supplemental oxygen.  Patient and family in agreement to respect patient's wishes in that he does not want to be intubated at this time.  Patient was weaned to 90% FiO2 this a.m..  Denies any changes in condition although appears to be more fatigued. Will continue current plan of care.  If patient does decompensate, will plan to provide comfort measures in support of patient's wishes not to be intubated or placed on ventilator.   Plan:  Ultrasound bilateral lower extremities negative for DVT will continue heparin drip for PE treatment due to increased decompensation. Patient unable to have CT for PE due to kidney function.  Continuous cardiac and pulse ox monitoring  Continue home albuterol and stiolto daily.  Lasix 40 mg IV daily, hold home diuretic lasix oral 40 mg daily Decadron 3/10 Not a candidate for remdezivir due to CKD although was given one dose on 11/15.  Continue pulmonary toliet.  Encourage proning as able.  PRN medication for symptom relief  Daily CBC, CMP, and CRP with D dimer to trend P.r.n. morphine and Ativan added for relief of oxygen hunger or agitation if necessary   Skin cancer Assessment & Plan Patient reports having two skin recessions from face on 11/15/2021. Sutures placed without need for removal. No current signs of infection.   Acute kidney injury superimposed on CKD  Assessment & Plan Patient with known CKD 3 baseline creatine 1.8 - 2.4.  Current creatinine 3.45.  Will continue to monitor.  Avoid nephrotoxins and renally dose medications when necessary   Paroxysmal atrial flutter  Assessment & Plan Rate controlled. Will hold anticoagulation while on heparin drip.   History of CVA (cerebrovascular accident) Assessment & Plan Patient with history of CVA. Denies residual symptoms.     Benign essential hypertension Assessment & Plan Stable.  Will continue home medications  Subjective    SUBJECTIVE: Patient did need at side of bed upon assessment.  Patient denies any change.  Patient reports he is waiting to "get cleaned up".  Patient continues to complain of shortness of breath.  Patient reports he is unable to lay on his abdomen but is very comfortable laying on his left side continuously.  Patient reports no other needs at this time.  Patient does verbalize he has talked to both his spouse and his daughter today.   Review of Systems Constitutional:  Positive for fatigue. Negative for chills and fever.  Respiratory:  Positive for cough, wheezing and shortness of breath.   Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Negative for nausea, vomiting and abdominal pain.  Genitourinary:  Negative for difficulty urinating and dysuria.  Neurological:  Negative for headaches.