Age: 89.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Alanine aminotransferase normal, Albumin globulin ratio normal, Angiogram pulmonary abnormal, Anion gap
Clinical narrative: Hospitalized (1.24.22 - 1.25.22); COVID-19 positive (1.24.22); Fully vaccinated PLUS boosted - moderna x3 D/c Summary:Discharge Summary PA-C (Physician Assistant-Certified) ? ? General Medicine Cosigned by: MD at 1/27/2022  2:41 PM Attestation signed by MD at 1/27/2022  2:41 PM I have personally interviewed and examined the patient on 1/27/2022. Management was discussed with PA-C. I agree with the documented findings and plan of care in his/her note.   Brief exam:General:  No acute distress Respiratory:  Clear to auscultation bilaterally, no wheezing, rhonchi, or crackles Cardiovascular:  Normal rate, regular rhythm, no murmur, no edema Gastrointestinal: soft, non-tender, non-distended; normal bowel sounds in all 4 quadrants Musculoskeletal: no bony abnormalities noted; able to move all 4 extremities spontaneously Neurologic:  Alert and oriented x4, no focal neurological deficits    Brief history and medical decision making:  89-year-old man with past medical history significant for interstitial lung disease, moderate persistent asthma presenting with increased dyspnea on exertion.  Found to be COVID-19 positive PCR.  Initially required 2 L by nasal cannula.  Was seen by pulmonology who did not suspect interstitial lung disease flare and did not feel that Decadron was indicated.  Patient was able to maintain greater than 95% on room air with activity.  Evaluated by pulmonary rehab with no indication for supplemental oxygen discharge.  Given elevated D-dimer and being COVID positive, patient at risk for DVT and was discharged on 7 days of VTE prophylaxis with Eliquis 2.5 mg 2 times a day.  Patient was discharged in medically stable condition.  Discharge instructions were discussed with patient.   BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/24/2022 Discharge Date: Jan 25, 2022   Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 01/25/2022 Unknown ? Pneumonia due to COVID-19 virus 01/24/2022 Unknown ? IPF (idiopathic pulmonary fibrosis) 10/02/2020 Yes ? Moderate persistent asthma without complication 10/02/2020 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute respiratory failure with hypoxia 01/25/2022 01/25/2022 Unknown Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:  left lower extremity claudication->recommend PCP follow up with ABI COVID->COVID at home program   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: 89 year old male with past medical history of moderate persistent asthma, interstitial lung disease, and Idiopathic pulmonary fibrosis not on home oxygen, paroxysmal AFib status post ablation, not anticoagulated, Hx DVT, chronic back pain, neuropathy, obstructive sleep apnea noncompliant with CPAP but uses oral appliance.  Patient presents to the emergency department at the recommendation of staff the pain clinic after presenting for steroid injection in being noted to have increased dyspnea with exertion.  Patient had reported feeling well other than slight increased shortness of breath with exercise for the past few days.  Emergency department patient was found to be COVID positive and requiring 2 L of supplemental oxygen.  He was quickly weaned to room air.  He was seen by pulmonary rehab and saturations maintained stable on room air with ambulation thus not qualifying for home oxygen.  Patient had negative troponins.  A limited echocardiogram was obtained and is pending read at time of discharge.  Patient has follow-up planned with Cardiology.  Patient noted calf pain and sensation of cold water running down his left leg while walking on the treadmill recently which is what he had planned follow up with Cardiology for. It was recommended to him he should discuss with his PCP and possibly have ABI completed.  Patient was started on Decadron at time of admission and was seen by pulmonology who did not feel he has a flare of his interstitial lung disease and symptoms were secondary to COVID. Did not feel decadron was indicated due to lack of lung parenchymal changes on CT. Will need to follow up with pulm to monitor for delayed COVID affects on ILD. Patient was discharged with eliquis 2.5mg BID x7 days for DVT prophylaxis in setting of COVID and previous DVT.    CONSULTS / RECOMMENDATION: Pulmonology Pulmonary rehab BP 116/50  | Pulse 79  | Temp 36.6 °C (Oral)  | Resp 22  | Ht 1.676 m  | Wt 83.7 kg  | SpO2 98%  | BMI 29.78 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is normal weight. He is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Comments: Deferred mask in place 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: Normal breath sounds.  Musculoskeletal:        General: No deformity.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.   H&P:  CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN:   # Acute hypoxic respiratory failure due to early COVID pneumonia and a possible ILD flare # IPF -Symptoms onset reported to be 1/20/22(symptoms very vague).  Tested positive on 1/24/22 -CT angio negative for PE, showed mild subpleural reticulation, groundglass attenuation, traction bronchiolectasis along with several areas of honeycombing without significant change compared to prior study consistent with UIP pattern, mild interval increase in size of ground glass nodule within the left upper lobe -chest x-ray report reviewed which showed left basilar atelectasis or pneumonitis -supportive and symptomatic treatment -Steroid recommendation per ED discussion with Pulm:  Continue Decadron 6 mg daily oral for now per COVID protocol -monitor daily COVID labs.  D Dimer elevated.   -wean oxygen as able.  May benefit from home oxygen evaluation prior to discharge -encourage proning and IS -Pulmonology Consult   # DOE, likely due to ILD, hypoxia.  Patient was supposed to follow-up with his cardiologist with concern for cardiac source as he also has been having vague symptoms of lower extremity paresthesias -last Echo showed a preserved EF and mild valvular disease in 2019 -check limited echo as the patient has COVID-19.  Follow-up with Cardiology and may need a complete echo outpatient   # Incidental indeterminate right upper pole renal lesion.  Renal mass possible. -dedicated CT or MRI of the kidneys on a nonurgent basis   # Moderate Persistent Asthma -continue Advair or formulary replacement   # Seasonal allergic rhinitis -continue p.r.n. Flonase and Ocean nasal spray   # history of prostate cancer with chronic radiation cystitis and proctitis # history of nephrolithiasis   # GERD with reflux esophagitis -continue PPI   # RLS -continue Requip   # Paroxysmal atrial fibrillation.  S/P Ablation -unclear if on baby aspirin for afib or pain(per med rec taking it weekly).  Not on anticoagulation -takes propanolol p.r.n. for tachycardia   # Hyperlipidemia -not on statin   # MDD # Anxiety disorder -continue Zoloft   # OSA with Oral appliance.  Cannot tolerate Bipap or CPAP -OSA power plan  -plans to bring in home oral appliance   # History of SSS with pacemaker   # Pre-diabetes -monitor   # Chronic back pain due to DJD  # Neuropathy -follows with the Pain Clinic for steroid injections -Tylenol PRN   # Code status Full per patient # Admit to inpatient, anticipate greater than 2 midnights inpatient stay # DVT prophylaxis with subcutaneous Lovenox HISTORY OF PRESENT ILLNESS: Patient is a 89 y.o. male who presents today with a past medical history of moderate persistent asthma, ILD not on oxygen, paroxysmal atrial fibrillation status post ablation not on anticoagulation, chronic back pain due to DJD, neuropathy, OSA noncompliant with CPAP or BiPAP, but uses a oral appliance and GERD who presented secondary to a chief complaint of ?shortness of breath ?.  Patient states that he has chronic dyspnea secondary to his ILD, but noted a slight increase in his shortness of breath 4 days prior to admission while he was walking on the treadmill.  Otherwise, he was feeling well.  He denied increase in his baseline cough or phlegm.  Denied increase in his chronic nasal congestion or rhinorrhea.  Denied fever or chills, chest pain, nausea, vomiting, diarrhea, loss of taste or smell, sore throat or fatigue.  He states he has known COVID contacts, including his son who he lives with and his grandson who had had some exposures.  He presented to the Pain Clinic to follow-up regarding steroid injections for his spine, but was noted while in the waiting room to be short of breath.  He states he barely noticed it, but the receptionist was concerned.  He was told to go to the emergency department.  He states that at home his oxygen levels have been stable between 93-97%.    In the emergency department, he was 88% on room air.  He was placed on 2 L nasal cannula.  Labs were drawn which showed a normal sodium, potassium, creatinine, LFTs, troponin x2, white blood cell count, hemoglobin, platelet count.  He had a D-dimer 1400.  COVID-19 was positive for PCR with a negative influenza and RSV.  Initial chest x-ray showed left basilar atelectasis or pneumonitis.  CT angiogram of the thorax showed no PE, no aortic abnormality, mild subpleural reticulation, ground-glass attenuation, traction bronchiolectasis along with several areas of honeycombing without significant change compared to the prior study consistent with usual interstitial pneumonia pattern interstitial lung disease, mild interval increase in size of a 7 x 4 mm ground-glass nodule in the left upper lobe verses 4 x 4 mm previously, recommending follow-up in 1 year.  Also incidentally noted indeterminate left upper pole renal lesion, possible renal mass.  Recommended CT or MRI of the kidneys on a nonurgent basis and a nonobstructive 6 mm stone in the upper pole of the right kidney.  He was given a dose of Decadron 6 mg IV. He was admitted to the Hospitalist service for possible early COVID pneumonia in the setting of ILD with hypoxic respiratory failure. No Known Allergies Review of Systems Constitutional:  Negative for appetite change, chills, fatigue and fever.  HENT: Positive for congestion and rhinorrhea. Negative for sore throat.       Chronic congestion and rhinorrhea.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, shortness of breath and sputum production. Negative for wheezing.        Chronic cough with sputum production.  DOE..  Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea, rectal bleeding and blood in stool.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Positive for back pain.       Chronic back pain.  Neurological:  Positive for numbness/tingling. Negative for headaches.       Chronic neuropathy in lower extremities.  He states he has been having episodes of numbness that ?rushes down into my toes like a water fall ?.  He noted an episode on his left thigh of numbness as well..  Skin:  Negative for rash.  OBJECTIVE: BP 129/73  | Pulse 84  | Temp 36 °C (Axillary) Comment: unable to obtain oral | Resp 19  | Wt 83.7 kg  | SpO2 97%  | BMI 26.55 kg/m²    Physical Exam Constitutional:      Appearance: He is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     General: No scleral icterus. Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: Rales present. No wheezing.     Comments: Overall respiratory status is stable, but the patient had episodes of conversational dyspnea and increased respiratory rate intermittently. Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No deformity.     Cervical back: Normal range of motion and neck supple. No rigidity.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.