Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Nasopharyngitis, Platelet count normal, Pneumonia, Pyrexia, Rales
Clinical narrative: Hospitalized (12.3.21 - 12/6/21); COVID-19 positive (12.3.21); Fully vaccinated - moderna x2  D/C summary: BRIEF OVERVIEW: Discharge Provider: DO Primary Care Provider at Discharge: MD   Admission Date: 12/3/2021 Discharge Date: 12/06/2021   Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 12/03/2021 Unknown ? Essential hypertension 12/03/2021 Unknown ? Type 2 diabetes mellitus with hyperglycemia  12/03/2021 Unknown   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute kidney injury  12/03/2021 12/06/2021 Unknown ? Lactic acidosis 12/03/2021 12/06/2021 Unknown ? Hypotension 12/03/2021 12/06/2021   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute kidney injury [N17.9] Community acquired pneumonia, unspecified laterality [J18.9] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 76-year-old male who presented to the emergency department with overall malaise, cough and fevers.  In the emergency department, patient was initially hypotensive which improved with IV fluids.  Lab work revealed acute kidney injury and lactic acidosis.  Chest x-ray concerning for left lower lobe pneumonia.  Patient also positive for COVID-19.  Patient was admitted to the Internal Medicine.  Lactic acidosis and acute kidney injury resolved during his stay.  He was started on antibiotics for community-acquired pneumonia.  He did develop acute hypoxemic respiratory failure requiring supplemental oxygen and was started on Decadron.  Patient overall felt improved.  Home oxygen was arranged.  Patient was recommended to wear 2 L nasal cannula with activity. DGMS was consulted for hyperglycemia given history of diabetes and on steroids.  Patient wanted to avoid injectable so Januvia was recommended in addition to patient's metformin.  Patient was recommended to increase monitoring of blood sugar at home and to avoid carbs while on steroids.  He was instructed to call his PCP with elevated blood sugars.  He was recommended to follow up his primary care physician.  He was discharged home in stable condition.     CONSULTS / RECOMMENDATION: DGMS   INPATIENT PROCEDURES: Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None BP 138/62  | Pulse 56  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.676 m  | Wt 68.7 kg  | SpO2 94%  | BMI 24.45 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress. HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.  Eyes:     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: No respiratory distress.     Comments: Faint bibasilar crackles Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.   H&P:  History and Physical   Date of Admission: 12/3/2021   Chief complaint Acute kidney injury    Assessment and Plan Principal Problem:   Acute kidney injury Active Problems:   COVID-19   Lactic acidosis   Hypotension   Essential hypertension   Type 2 diabetes mellitus with diabetic nephropathy      PLAN AKI Hypotension, POA--resolved Lactic acidosis: - appeared volume depleted in ED.  Receiving IVFs and BPs improving - repeat BMP in AM.  Baseline uncertain, but appears to be around 1 on community viewer - avoid nephrotoxins - renally dose medications   COVID-19: - Patient was vaccinated April 2021, had not received booster yet - symptom onset 7 days ago - COVID (+) PCR 12/03 - not requiring supplemental O2 - chest xray shows left lower lobe infiltrate, though not necessarily appearing like COVID pneumonia - no decadron at this time  - not candidate for remdesivir - may be candidate for monoclonal antibodies.  Patient would be agreeable with this.  Can notify team in AM   Community acquired pneumonia: - concerning for near sepsis given hypotension on admission (resolved), lactic acidosis and likely pneumonia - check procalcitonin - continue rocephin and azithromycin at this time - blood cultures obtained in ED.  Continue to follow   Essential hypertension: - BPs were low initially, but improved with IVFs - continue to monitor - hold home mediations for now and resume if BPs remain stable     DVT prophylaxis: heparin sq Code Status:  Full code, per discussion with patient   History obtained from patient, ED physician/records, and personally reviewed past medical records.   History of Present Illness Patient is a 76 y.o. male who presents today feeling unwell.  He has been feeling generally unwell with what he calls a "head cold" since about 7-8 days ago.  He had cough, congestion, fevers.  He first noted symptoms 8 days ago with subjective fevers and feeling weak and confused and shaky.  This seemed to wax and wane over next few days.  Cough subsided.  Today he seemed confused, weak and overall unwell so came to ED.  He denies any chest pain, abdominal pain, nausea/vomiting.  Appetite has been okay.  He had 2 days of diarrhea, which have resolved.  His wife notes that he does have some confusion as well.   In the Ed, the patient was initially found to be hypotensive, which quickly improved with IVFs.  Labs shows a new AKI, and elevated LA.  Chest xray concerning for LLL pneumonia.  Given rocephin and azithromycin in ED.