Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Chest X-ray normal, Chronic kidney disease, Computerised tomogram head normal, Condition aggravated, Confusional state
Clinical narrative: Hospitalized (4.17.22 - 4.29.22); COVID-19 positive (4.16.22); fully vaccinated PLUS Booster - pfizer x3 d/c summary:Discharge Summary (Physician) ? ? General Medicine BRIEF OVERVIEW: Admission Date: 4/17/2022 Discharge Date: Apr 29, 2022 Active Hospital Problems   Diagnosis Date Noted POA ? Pressure injury of sacral region, unstageable 04/18/2022 Yes ? Weakness 04/17/2022 Yes ? Weakness 07/06/2018 Yes  Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? NSTEMI (non-ST elevated myocardial infarction) 04/18/2022 04/29/2022 Yes  Discharge Disposition:  skilled nursing facility    Active Issues Requiring Follow-up: CKDIIIA, hyponatremia: Repeat BMP in 2-3 days to followup sodium levels. Needs to continue ISC q8H for urinary retention, would benefit from referral to urology if retention persists. Needs ongoing wound care for sacral decubitus ulcer.  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness NSTEMI (non-ST elevated myocardial infarction) HOSPITAL COURSE: 74 year old male with history of history of type 2 diabetes, cauda equina syndrome with neurogenic bladder, OSA, hypertension, CKD three, seizure disorder, TBI with cognitive impairment, depression/anxiety, anemia of chronic disease who presented with generalized weakness and COVID infection. He did not have hypoxia so it did not require treatment for COVID and supportive care was provided. His AKI resolved with IV hydration. He had echocardiogram for elevated troponins which came back negative for WMA.   Patient completed his 10 days of severe respiratory precautions while in the hospital. His stay was complicated by worsening hyponatremia which was thought to be due to volume depletion. Nephrology was consulted and He was started on gentle IVF and given NaCl 1g x1. He was also found to have UTI with UCx growing pansensitive ecoli. He was continued on Rocephin and discharged on cefdinir to complete course a 7 day total course of antibiotics. Discharged to subacute rehab in stable condition with instructions for q8H ISC for urinary retention and repeat BMP in 2-3 days to followup sodium level and renal function.  CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward) IP CONSULT TO NEPHROLOGY IP CONSULT TO WOUND Provider:  Limb Care & Preservation Clinic Wound Healing INPATIENT PROCEDURES: BP (!) 140/49  | Pulse 93  | Temp 36.5 °C (Oral)  | Resp 16  | Ht 1.778 m  | Wt 124 kg  | SpO2 98%  | BMI 39.22 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.   No gallop.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing, rhonchi or rales.  Abdominal:     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No swelling.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.    H&P:Hospitalist  History & Physical  CHIEF COMPLAINT: Weakness   ASSESSMENT/PLAN: Patient is a 74 y.o. male presenting with Weakness.    COVID-19 infection Generalized weakness Ground level fall Developed symptoms approximately two weeks prior to admission, date of positive test 4/16 Chest x-ray and shoulder x-ray demonstrates no acute findings Pending D-dimer, if markedly elevated will obtain CTA given tachycardia with ambulation Patient is not a candidate for advanced therapy such as Decadron or remdesivir Lovenox for DVT prophylaxis Daily COVID-19 labs Continuous pulse oximetry Symptomatic treatment with tylenol, antitussives, PRN albuterol, etc PT/OT consult Care Management consulted, likely not safe for patient to return home in the setting of his caregiver being hospitalized   AKI on CKD three - mild, secondary to below and potential urinary retention Poor oral intake Patient has not been eating or drinking well since his primary caregiver, his wife, has been hospitalized Status post 1.5 L of IV fluids Encourage oral intake Nutrition consult Repeat creatinine in the morning   Acute urinary retention Neurogenic bladder Foley placed in the ER due to PVR 400 Consider voiding trial in the next day   ?AMS - 2/2 below and acute COVID infection with poor PO Acute on chronic anxiety Depression TBI with subsequent cognitive impairment Patient's primary caregiver, his wife, is currently hospitalized and he has been quite anxious with her absence CT head without acute findings Redirection and reassurance P.r.n. Atarax for anxiety Continue home Paxil, Risperdal, BuSpar   Hypertension Patient was quite hypertensive on presentation as he had not taken his medications, greatly improved with receiving his home medications Continue home losartan, clonidine, amlodipine   Seizure disorder Continue home Vimpat   Insulin-dependent type 2 diabetes Decrease home Lantus to 20 units nightly Low-dose corrective insulin Holding home Actos Continue home aspirin and statin Continue home gabapentin   Decubitus ulcer Present on admission, this appears to be new, patient has been sitting in his power chair quite a bit Wound consulted   Neurodermatitis Atarax PRN for itching  Anemia of chronic disease Monitor with complete blood count in the morning, hemoglobin slightly worse than baseline OSA OSA order set Code: Full DVT ppx: Lovenox Diet: Diabetic HISTORY OF PRESENT ILLNESS:   Patient is a 74 y.o. male with a past medical history of type 2 diabetes, cauda equina syndrome with neurogenic bladder, OSA, hypertension, CKD three, seizure disorder, TBI with cognitive impairment, depression/anxiety, anemia of chronic disease who presents with weakness found to have COVID-19 infection and AKI.  Patient's primary caregiver is his wife was unfortunately hospitalized at this time, he has been having difficulty managing at home.  He has had limited oral intake, very poor sleep, progressive weakness and confusion, and he fell at home today.  He did not strike his head, but he struck his left shoulder.  He is feeling very anxious and stressed because his wife is not home. H reports a cough two weeks ago that is improving.   In the emergency department, he was noted to be hypertensive, afebrile, mildly tachycardic and tachypneic satting well on room air.  Labs revealed creatinine 2.03 from baseline 1.7, WBC 8.2, hemoglobin 9.2 from baseline 10.5, troponin 73 -> 63, BNP 453, lactic acid 1.4, unremarkable UA.  He was found to be COVID-19 positive.  EKG revealed biphasic T-waves in the lateral leads which is new from prior.  Chest x-ray was unremarkable and left shoulder x-ray demonstrated no acute abnormality.  CT head demonstrated no acute abnormality.  He was found to have urinary retention with 400 mL PVR, so a Foley was placed.  Given his anxiety which is acute on chronic, he was given a dose of Ativan which improved his symptoms.  He was also noted to be quite hypertensive so he was given his home antihypertensives.  He was also given 1.5 L of fluid.  Patient was unsafe to return home given his weakness and his primary caregiver is available.  He was admitted to Internal Medicine under observation for further evaluation and management. Prior physician notes, labs, imaging reviewed. Review of Systems: Review of Systems Constitutional:  Positive for fatigue. Negative for fever.  HENT: Negative for sore throat and trouble swallowing.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough. Negative for shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Negative for abdominal pain, constipation, diarrhea and trouble swallowing.  Genitourinary:  Positive for difficulty urinating. Negative for dysuria.  Neurological:  Positive for weakness. Negative for headaches.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Positive for anxiety and sleep disturbance.  Skin:  Positive for wound. Negative for rash.      OBJECTIVE:   BP 163/52  | Pulse 81  | Temp 36.8 °C (Oral)  | Resp 20  | SpO2 99%  Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not diaphoretic.     Comments: Lying in bed, appears comfortable  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.   No friction rub. No gallop.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. 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 guarding.  Musculoskeletal:        General: No edema.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Findings: No erythema.     Comments: Multiple areas of excoriation and scabs from recurrent itching.  Decubitus ulcer noted on skin check  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Comments: Very poor historian  Psychiatric:        Mood and Affect: Mood and affect normal.        Behavior: Behavior normal.