Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Gait disturbance, General physical condition abnormal, Glomerular filtration rate normal, Haematocrit decreased, Haematuria traumatic
Clinical narrative: Hospitalized (1.5.22 - 1.11.22); COVID-19 positive (12.29.21); Fully vaccinated  - moderna x2 d/c summary: Discharge Summary MD (Resident) ? ? General Medicine Cosigned by: MD at 1/11/2022  4:00 PM Attestation signed by, MD at 1/11/2022  4:00 PM I discussed the history/exam with the Resident on 1/11/2022.  I agree with the findings and the Plan of Care as documented in the resident's note.   I saw and evaluated the patient. I spent 35 minutes performing this hospital discharge.   BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/5/2022 Discharge Date: Jan 11, 2022   Hospital problems: Generalized weakness Multiple falls at home Urinary retention with Foley in place Possible traumatic Foley Benign prostatic hyperplasia COVID-19 infection Transaminitis Essential hypertension Coronary artery disease Hyperlipidemia Seizure disorder Dementia At risk for falls Anxiety and depression Gastroesophageal reflux disease Peripheral nerve disease Restless leg syndrome      Medication List   CHANGE how you take these medications  tamsulosin 0.4 MG capsule Commonly known as: FLOMAX take 2 capsules by mouth once daily What changed:  o how much to take o when to take this DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness [R53.1] COVID-19 [U07.1]   HOSPITAL COURSE: 77 year old male with PMHx coronary disease, chronic renal insufficiency, dementia, indwelling Foley catheter admitted for generalized weakness, falls, and urinary retention.   Patient presented to the emergency department with ongoing generalized weakness leading to difficulty ambulating with his walker and multiple falls at home. ED course: Troponins normal at 9, 10. CBC without leukocytosis, anemia, or thrombocytopenia.  Urinalysis showing >300 protein, moderate leukocytes, >75 RBCs, 8 WBCs. No hyaline casts or squamous epithelial cells to indicate contamination.  Urine grossly bloody. EKG with normal sinus rhythm, ventricular rate of 95, QTc 459 ms. Left axis deviation.  Nonspecific ST and T-wave abnormality seen. 500 mL fluid bolus given. Accepted for admission under observation to the general medicine service.   In the hospital he was seen by Physical therapy and Occupational therapy.  They recommended subacute rehab.  He received 2 days of Rocephin 1 g daily for suspicion for urinary tract infection but urine culture grew resident flora.  Benadryl as a sleep aid was discontinued.  His Dilantin levels were drawn and shown to be low.  He will need follow-up with Neurology.  Orthostatic vital signs normal.  He continued to be stable throughout the admission with continuing signs of generalized weakness.  He was transferred to subacute rehab for further care.   CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES: BP 116/62  | Pulse 91  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.727 m  | Wt 90.4 kg  | SpO2 96%  | BMI 30.30 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is obese. He is not diaphoretic.  HENT:     Head: Normocephalic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: Abdomen is flat. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.     Comments: Trembling with movement  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.   H&P: Attestation signed by, DO at 1/5/2022 10:24 PM I have personally interviewed and examined the patient on 1/5/2022. Management was discussed with Dr. I agree with the documented findings and plan of care in his/her note.   Brief exam: alert, elderly man in no acute distress. Oriented to person, place, time and general situation though some details seem difficult for him to recall. Foley in place with reddish urine. Non-tender abdomen. No focal neurologic deficits. Non labored respirations and heart sounds have RRR.    Brief history and medical decision making:  77-year-old man with recent diagnosis of COVID-19 and multiple falls at home over the past several weeks.  Wife noticed him trip on his Foley catheter and subsequent blood in the Foley.  Seen initially at outside hospital and discharged after Foley replacement and initiation of Keflex for possible urinary tract infection.  Today he is admitted for generalized weakness suspected to be from COVID-19 infection; diagnosed at outside hospital on 12/29/2021.  Symptom onset 12/28.  Vaccinated but without booster and received monoclonal antibodies 3-4 days ago.  Denies shortness of breath and is on room air.  Will obtain PT & OT evaluation and recommendations.   Patient also noted to have hematuria, likely traumatic in nature based on history but may have associated urinary tract infection.  Urine culture pending.  Will plan for Rocephin daily and follow urine culture.  History of E coli and Proteus infections.  Patient and wife expressed do not resuscitate/DNI wishes.  Expand All Collapse All     Hide copied text  Hover for details    Inpatient Hospitalist History & Physical          CHIEF COMPLAINT: Generalized weakness Falls at home   Subjective       HISTORY OF PRESENT ILLNESS: Patient is a 77 year old male with past medical history significant for coronary artery disease with STEMI s/p DES to RCA in 2018, hypertension, hyperlipidemia, GERD, anxiety, depression, seizure disorder, BPH, indwelling Foley catheter, restless leg syndrome, peripheral nerve disease, and current COVID-19 infection presents emergency department with chief complaint of generalized weakness and multiple falls at home.   Past majority of the history is obtained by chart review and previous records. Also obtained by wifeover the phone.  Patient has been to an outside hospital emergency department 2 times in the past 2 days, 1/3/22 and 1/4/22.  Each time, he was sent home.  Most recently, he was sent home with Keflex to treat a urinary tract infection and recommendations for home health care services.  However, his wife never picked up the Keflex.  Per chart review, the patient's wife states he has been experiencing increasingly worsening generalized weakness leading to difficulty holding his body up, ambulating with his walker, and multiple falls at home.  He is not hit his head or lost consciousness per his wife but does have some bruising on his buttock and extremities.  He has an indwelling catheter that was placed several months ago for chronic out obstruction.  He follows with a Urologist. The patient's wife called his Urology office yesterday stating that she had not seen any urine in his catheter bag since 3:00 a.m. the night before.  She was also noticing blood in his bag.  She does report that she noticed he tripped on his foley the other night, which might have caused some of the bleeding, but she isn't sure.  Reportedly, his catheter was replaced yesterday at Facility with return of urine. She does not feel she can adequately take care of him at home and is hoping he will go to a rehab facility to get stronger prior to returning home. She says that each time he falls, she has to call EMS and it takes 3 people to get him up and into a chair or bed.     ED course: Labs ordered including complete blood count, CMP, troponin, urinalysis. Troponins normal at 9, 10. CBC without leukocytosis, anemia, or thrombocytopenia.  Electrolytes including sodium (136), potassium (4.2), chloride (101), bicarbonate (21) all within normal range.  Glucose mildly elevated to 127.   Renal function normal with GFR >60, BUN 11, and Cr 0.74.  Alkaline phosphatase mildly elevated to 132, AST elevated to 77, ALT elevated to 42, bilirubin normal at 0.5.   Urinalysis showing >300 protein, moderate leukocytes, >75 RBCs, 8 WBCs. No hyaline casts or squamous epithelial cells to indicate contamination.  Urine grossly bloody. EKG with normal sinus rhythm, ventricular rate of 95, QTc 459 ms. Left axis deviation.  Nonspecific ST and T-wave abnormality seen. 500 mL fluid bolus given. Accepted for admission under observation to the general medicine service.   Review of Systems  Constitutional: Positive for chills and malaise/fatigue. Negative for fever.  HENT: Negative for congestion and sore throat.   Eyes: Negative for pain and redness.  Respiratory: Negative for cough, shortness of breath and wheezing.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Negative for abdominal pain, blood in stool, nausea and vomiting.  Genitourinary: Positive for hematuria. Negative for dysuria and flank pain.  Musculoskeletal: Positive for falls and myalgias.  Skin: Negative for rash.  Neurological: Positive for weakness. Negative for dizziness.  Psychiatric/Behavioral: Positive for memory loss (short term, chronic Objective    OBJECTIVE: BP 120/59  | Pulse 94  | Temp 36.9 °C (Oral)  | Resp 15  | Ht 1.727 m  | Wt 90.4 kg  | SpO2 94%  | BMI 30.30 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is obese. He is ill-appearing.     Comments: Lying on his right side in the hospital bed, visibly shaking.  States he is cold.  Stops shaking after 2nd blanket placed over him.  He appears very tired.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no right CVA tenderness or left CVA tenderness.  Genitourinary:    Comments: Foley catheter in place Musculoskeletal:     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.     Comments: Able to tell me his full name, date of birth, where he is located, and why he is in the hospital.  He is having trouble speaking at times due to fatigue.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.