Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Rhinorrhoea, Rib fracture, SARS-CoV-2 test positive, Sinus rhythm, Thrombocytopenia
Clinical narrative: Attending Physician:     Date of Admission:  4/8/2022   Chief Complaint:  Weakness   Source of Information:  Patient, patient's son   History of Present Illness:  This is a 72y.o. male with past medical history significant for rheumatoid arthritis on methotrexate and prednisone, T2DM, hypothyroidism, bronchitis presents to the hospital with complaints of generalized weakness and diminished appetite for the past week.  Patient's son is at bedside to provide majority of history.  He states that his father has had a diminished appetite with progressive weakness with associated shortness of breath, cough, rhinorrhea.  Patient's wife did complain of URI symptoms with sore throat and cough last week.  Patient received 2/2 Covid vaccine.  He denies fever, chills, nausea, vomiting, chest pain, palpitations, diarrhea, constipation.  He does endorse a significant smoking history, smoked 2 packs for 30+ years and quit 15+ years ago.  Denies any supplemental oxygen, utilizes Incruse Ellipta, Ventolin, Singulair at home with benefit.  Of note, patient slipped on the ice and fractured 3 ribs on the left with no acute intervention required.   Upon evaluation in the ED, vital signs demonstrate BP 153/70, RR 24, HR 111, afebrile.  Patient SPO2 90% on room air and subsequently transitioned to 2 L nasal cannula with SPO2 in the high 90s.  Work-up significant for thrombocytopenia, mildly elevated D-dimer, COVID-19 positive.  Chest x-ray demonstrating left basilar airspace disease, CTA pending for completeness.  Patient to be admitted to medicine with consult placed to ID given need for supplemental oxygen and considerations for remdesivir therapy.    Past Medical History: Diagnosis Date ? Asthma   ? Chronic bronchitis   ? Diabetes mellitus  ? RA (rheumatoid arthritis)  Past Surgical History: Procedure Laterality Date ? HIP SURGERY       L side ? RESECTION, SMALL BOWEL        Family History Problem Relation Age of Onset ? Emphysema Mother   ? No Known Problems Father      Social History    Tobacco Use ? Smoking status: Former Smoker     Packs/day: 2.00     Years: 34.00     Pack years: 68.00     Types: Cigarettes ? Smokeless tobacco: Never Used Substance and Sexual Activity ? Alcohol use: No ? Drug use: No         Medications:   Home Medications     Reviewed by Registered Nurse on 04/08/22 at 1804  Med Sig Last Dose Dt/Time  budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT INHAL inhaler inhale 2 Puffs into the lungs twice daily.    folic acid (FOLATE) 1 MG PO Tab take 1 mg by mouth once daily.    ibuprofen (MOTRIN) 600 MG PO Tab take 1 Tablet by mouth every 8 hours as needed for FOR MILD PAIN or FOR MODERATE PAIN.    insulin aspart (NovoLOG FLEXPEN) 100 UNIT/ML SQ Solution Pen-injector inject  into the skin. As directed.    levothyroxine (SYNTHROID, LEVOTHROID) 50 MCG PO Tab take 50 mcg by mouth once daily before breakfast.    lidocaine (LIDODERM) 5 % EXTERNAL Patch place 1 Patch onto the skin once daily.    metFORMIN (GLUCOPHAGE) 500 MG PO Tab take 500 mg by mouth twice daily.    montelukast (SINGULAIR) 10 MG PO Tab take 10 mg by mouth once every night at bedtime.    Pancrelipase, Lip-Prot-Amyl, (CREON PO) take  by mouth.    predniSONE (DELTASONE) 1 MG PO Tab take 1 Tab by mouth twice daily.    traMADol (ULTRAM) 50 MG PO Tab take 50 mg by mouth every 6 hours as needed.    TRESIBA FLEXTOUCH 100 UNIT/ML SQ Solution Pen-injector inject 50 Units into the skin once every night at bedtime.    Umeclidinium Bromide (INCRUSE ELLIPTA) 62.5 MCG/INH INHAL AEROSOL POWDER, BREATH ACTIVATED inhale 1 Puff into the lungs once daily.    VENTOLIN HFA 108 (90 Base) MCG/ACT INHAL Aero Soln inhale 2 Puffs into the lungs twice daily.             Hospital Medications:   Current Medications Current Facility-Administered Medications Medication Dose Route Frequency Provider Last Rate Last Admin ? acetaminophen (TYLENOL) tablet 650 mg  650 mg Oral Q 6 H      ? albuterol-ipratropium (DUONEB) nebulizer solution 3 mL  3 mL Inhalation Q 6 H 3 mL at 04/09/22 0107 ? [START ON 4/10/2022] dexamethasone (DECADRON) injection 6 mg  6 mg Intravenous DAILY ? enoxaparin (LOVENOX) injection 40 mg  40 mg Subcutaneous Q 24 H     ? fluticasone-vilanterol (BREO ELLIPTA) 100-25 MCG/INH inhaler 1 Puff  1 Puff Inhalation DAILY      ? folic acid (FOLATE) tablet 1 mg  1 mg Oral DAILY     ? insulin glargine (LANTUS) injection HIGH ALERT 24 Units  24 Units Subcutaneous Q HS      ? ipratropium (ATROVENT HFA) 17 MCG/ACT inhaler 1 Puff  1 Puff Inhalation DAILY ? levothyroxine (SYNTHROID, LEVOTHROID) tablet 50 mcg  50 mcg Oral DAILY     ? montelukast (SINGULAIR) tablet 10 mg  10 mg Oral Q HS     ? predniSONE (DELTASONE) tablet 1 mg  1 mg Oral BID     ? traMADol (ULTRAM) tablet 50 mg  50 mg Oral Q 6 H PRN  Current Outpatient Medications Medication Sig Dispense Refill ? insulin aspart (NovoLOG FLEXPEN) 100 UNIT/ML SQ Solution Pen-injector inject  into the skin. As directed.     ? levothyroxine (SYNTHROID, LEVOTHROID) 50 MCG PO Tab take 50 mcg by mouth once daily before breakfast.     ? Pancrelipase, Lip-Prot-Amyl, (CREON PO) take  by mouth.     ? budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT INHAL inhaler inhale 2 Puffs into the lungs twice daily.     ? folic acid (FOLATE) 1 MG PO Tab take 1 mg by mouth once daily.   5 ? ibuprofen (MOTRIN) 600 MG PO Tab take 1 Tablet by mouth every 8 hours as needed for FOR MILD PAIN or FOR MODERATE PAIN. 30 Tablet 0 ? lidocaine (LIDODERM) 5 % EXTERNAL Patch place 1 Patch onto the skin once daily. 15 Patch 0 ? metFORMIN (GLUCOPHAGE) 500 MG PO Tab take 500 mg by mouth twice daily.   3 ? montelukast (SINGULAIR) 10 MG PO Tab take 10 mg by mouth once every night at bedtime.   3 ? predniSONE (DELTASONE) 1 MG PO Tab take 1 Tab by mouth twice daily.   3 ? traMADol (ULTRAM) 50 MG PO Tab take 50 mg by mouth every 6 hours as needed.     ? TRESIBA FLEXTOUCH 100 UNIT/ML SQ Solution Pen-injector inject 50 Units into the skin once every night at bedtime.   3 ? Umeclidinium Bromide (INCRUSE ELLIPTA) 62.5 MCG/INH INHAL AEROSOL POWDER, BREATH ACTIVATED inhale 1 Puff into the lungs once daily. 3 Each 3 ? VENTOLIN HFA 108 (90 Base) MCG/ACT INHAL Aero Soln inhale 2 Puffs into the lungs twice daily.   3      Allergies:    No Known Allergies   ROS: Constitutional: Admits generalized weakness, diminished appetite.  Denies fever or chills  Eyes:  Denies change in visual acuity, eye pain  HENT:  Denies nasal congestion or sore throat  Respiratory:  Denies cough or shortness of breath  Cardiovascular:  Denies chest pain or edema  GI:  Denies abdominal pain, nausea, vomiting, bloody stools or diarrhea  GU:  Denies dysuria, hematuria   Musculoskeletal:  Denies back pain or joint pain  Integument:  Denies rash, papules Neurologic:  Denies headache, focal weakness or sensory changes  Endocrine:  Denies polyuria or polydipsia  Lymphatic:  Denies tender or enlarged lymph nodes  Psychiatric:  Denies depression or anxiety                            Last Filed Vitals: BP 144/63  | Pulse 106  | Temp 97.5 °F (36.4 °C)  | Resp 20  | Ht 175.3 cm (5' 9")  | Wt 86.2 kg (190 lb)  | SpO2 96%  | BMI 28.06 kg/m²  Body mass index is 28.06 kg/m².   Physical Examination:    Constitutional: Appears comfortable, no acute distress.  No conversational dyspnea, no accessory muscle use, appears stated age HENT: No nasal drainage, external ears appear normal, mucous membranes moist. Eyes: PERRLA, no icterus, no pallor.  Neck: No lymphadenopathy or thyromegaly, trachea midline Cardiovascular: Regular rate and rythym, no murmurs, rubs or gallops, no peripheral edema, no carotid bruits  Pulmonary/Chest: No use of accessory muscle, no conversational dyspnea, chest was clear to auscultation bilaterally, no wheezing, no crackles. Gastrointestinal: Abdomen was soft, non-tender, non-distended, no masses felt, no hepatosplenomegaly. Musculoskeletal: Tender to palpation over the left chest wall consistent with known rib fractures, no clubbing or cyanosis, full range of motion in all extremities. Neurological: No focal motor or sensory deficits. Skin: No skin rash, no palpable nodules. Psychiatric: Alert and oriented x 3. Appropriate mood and affect   Labs:  Recent Results Recent Results (from the past 24 hour(s)) aPTT   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   APTT 32.7 25.0 - 38.0 Seconds Protime Normalized Ratio (NR)   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Protime 13.1 9.2 - 13.5 Seconds   NR 1.2   Basic Metabolic Panel (BMP)   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Sodium 138 135 - 145 mmol/L   Potassium 4.4 3.5 - 5.2 mmol/L   Chloride 101 98 - 111 mmol/L   Carbon Dioxide (CO2) 25 20 - 29 mmol/L   Anion Gap 12 5 - 17   Glucose 173 (H) 60 - 99 mg/dL   Blood Urea Nitrogen (BUN) 13 7 - 25 mg/dL   Creatinine 0.88 0.60 - 1.30 mg/dL   Calcium 8.9 8.5 - 10.5 mg/dL D-Dimer   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   D-Dimer 800 (H) 0 - 499 ng/mL FEU Magnesium Level   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Magnesium 1.9 1.7 - 2.5 mg/dL Phosphorus Level   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Phosphorus 2.3 2.3 - 4.4 mg/dL Troponin I   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Troponin I 0.01 <=0.03 ng/mL Thyroid Stimulating Hormon (TSH) With Reflex to Free Thyroxine (FT4)   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Thyroid Stimulating Hormone 2.26 0.40 - 4.50 uIU/mL Beta Hydroxybutyrate (3OH Butyric Acid)   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Beta Hydroxybutyrate (3-OH Butyric Acid) 0.69 (H) 0.02 - 0.27 mmol/L Complete Blood Count (CBC) W/Auto Diff   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   WBC 5.1 3.5 - 10.1 bil/L   RBC 4.51 4.31 - 5.48 tril/L   Hemoglobin 13.4 (L) 13.5 - 17.0 g/dL   Hematocrit 41.4 40.1 - 50.1 %   MCV 92 80 - 100 fL   MCH 30 28 - 33 pg   MCHC 32 32 - 36 g/dL   RDW-CV 15 12 - 15 %   Platelets 84 (L) 150 - 400 bil/L Manual Differentia   Collection Time: 04/08/22  8:53 PM Result Value Ref Range   Neutrophils 2.3 1.6 - 7.2 bil/L   Lymphocytes 0.9 (L) 1.1 - 4.0 bil/L   Monocytes 1.8 (H) 0.0 - 0.9 bil/L   Eosinophils 0.0 0.0 - 0.4 bil/L   Basophils 0.0 0.0 - 0.1 bil/L   RBC Morphology Unremarkable     Platelet Estimate Decreased (A) Adequate Covid-19, Flu, RSV by NAA   Collection Time: 04/08/22  9:06 PM   Specimen: Nasopharyngeal; Swab Result Value Ref Range   Influenza A Not Detected Not Detected   Influenza B Not Detected Not Detected   RSV Not Detected Not Detected   SARS-CoV-2 (COVID-19) by NAA, Micro  Detected (A) Not Detected Blood Gases, Venous (VBG)   Collection Time: 04/08/22  9:06 PM Result Value Ref Range   Sample Type Blood, venous     pH 7.34 7.32 - 7.42   PCO2 50 41 - 51 mmHg   Bicarbonate 26 19 - 27 mmol/L   Total CO2 28 20 - 29 mmol/L   Base Excess 0 -5 - 5 mmol/L   Oxyhemoglobin 29 (L) 55 - 85 %   Carboxyhemoglobin 0.5 <1.5 %   Methemoglobin 0.5 0.0 - 2.0 %   Hemoglobin 13.1 (L) 13.5 - 17.0 g/dL      Diagnostic Studies:    Result Date: 4/8/2022 4/8/2022 10:07 PM ECG *Document ECG Separate from all other Procedures* Date/Time: 4/8/2022 6:04 PM Performed by: Authorized by: Contemporaneously ECG reviewed by ED Physician in the absence of a cardiologist: yes  Interpretation:   Interpretation: abnormal  Rate:   ECG rate:  103   ECG rate assessment: normal  Rhythm:   Rhythm: sinus rhythm  Ectopy:   Ectopy: none  Conduction:   Conduction: abnormal    Abnormal conduction: bifascicular block  ST segments:   ST segments:  Normal T waves:   T waves: normal     US THYROID   Result Date: 3/14/2022 CLINICAL INDICATION: Thyroid goiter COMPARISONS: No priors. TECHNIQUE: A sonogram of the thyroid gland was performed assessing gray-scale appearance and color doppler flow. FINDINGS: The right thyroid lobe is mildly enlarged in size measuring approximately 4.1 x 2.1 x 1.6 cm in longitudinal, AP, and transverse dimensions.  There is homogeneous echotexture without nodules, cysts, or masses. The left thyroid lobe is enlarged in size measuring approximately 4.7 x 2.3 x 1.7 cm in longitudinal, AP, and transverse dimensions.  Nodule 1: Isoechoic solid nodule within the midpole measuring 1.0 x 1.3 x 1.4 cm. No internal echogenic foci. Smooth margin. TI-RADS category 3. Inferior to the left thyroid lobe there is a solid hyperechoic structure measuring 0.8 x 0.6 x 0.5 cm. The isthmus appears unremarkable. IMPRESSION: 1. Enlarged thyroid gland with a TI-RADS category 3 left thyroid lobe nodule. No indication for FNA. Surveillance ultrasound in 1, 3 and 5 years is recommended. 2. Additional hyperechoic solid lesion inferior to the left thyroid lobe measuring 0.8 cm. Consider nuclear medicine parathyroid scan to evaluate for underlying parathyroid adenoma.    CHEST 1 VIEW AP/PA   Result Date: 4/8/2022 CLINICAL INDICATION:  SOB (shortness of breath) COMPARISON: Chest radiograph 10/26/2017 TECHNIQUE:  Single frontal projection of the chest FINDINGS:  Patchy left basilar airspace opacity is seen with obscuration of the left hemidiaphragm. There is no evidence for pneumothorax or pleural effusion. There is a normal cardiac silhouette.  No acute osseous abnormalities are identified.  Remote left-sided rib fractures are noted. IMPRESSION: Left basilar airspace disease, correlate for pneumonia.       Assessment and Plan:    Active Hospital Problems   Diagnosis ? COVID-19 virus detected ? Acute respiratory failure with hypoxia ? SOB (shortness of breath) ? Thrombocytopenia ? Positive D dimer ? Chronic bronchitis ? Type 2 diabetes mellitus ? RA (rheumatoid arthritis)       PLAN -COVID-19 pneumonia, chest x-ray with left-sided basilar airspace disease, CTA PE pending for completeness in light of elevated D-dimer and need for oxygen supplementation.  ID consulted for considerations of remdesivir therapy.  IV Decadron 6 mg x 10 days.  Pulse oximetry, closely monitor respiratory status -I will cytopenia of questionable significance, suspect secondary to COVID-19 infection, peripheral smear and fibrinogen pending for completeness.  Coags WNL -History of rheumatoid arthritis on methotrexate and prednisone, unaware of methotrexate dosage and son to provide dosage tomorrow, q. once weekly dosing on Saturdays.  Continue prednisone -Continue DuoNeb, Breo, Singulair for chronic bronchitis    Progressive Activity: As tolerate PT/OT: Eval pending DVT PPX: Lovenox Diet: Diabetic     -Patient with COVID-19 pneumonia.  Started on remdesivir and Decadron.  He there is a language barrier. Will stop his prednisone and initiate Decadron.  May switch back to prednisone after 10-day of Decadron therapy completed.  CT scan performed and no pulmonary embolism currently present.  Titrate oxygen as needed.  Lovenox for DVT prophylaxis.  Continue with Lantus and 2 units sliding scale insulin coverage.  See orders for further care plan. Patient seen and examined in emergency department.  I reviewed the resident's note and revised the findings and/or plan of care as documented above.   Date:   4/9/2022     ED to Hosp-Admission (Discharged) on 4/8/2022     ED to Hosp-Admission (Discharged) on 4/8/2022       Revision History       Detailed Report     Note shared with patient    Revision History    Chart Review Routing History  No routing history on file.