Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Alanine aminotransferase normal, Anion gap, Anticoagulant therapy, Anxiety, Aspartate aminotransferase normal
Clinical narrative: Hospitalized (2.20.22 - 3.3.22); COVID-19 positive (2.19.22); Fully vaccinated -J&J X1 d/c summary:  Discharge Summary                                          Discharge Information:    Procedures to be scheduled by PCP: None   Results/Procedures requiring PCP followup: None   Admission Date: 2/20/2022 Discharge Date: 03/03/2022  Admitting Diagnoses: COVID-19   Discharge Diagnoses: Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 03/01/2022 Yes ? Multiple sclerosis, primary progressive 07/14/2017 Yes ? HTN (hypertension) 11/14/2018 Yes ? Neurogenic bladder 06/06/2018 Yes ? Cognitive dysfunction accompanying multiple sclerosis  06/06/2018 Yes ? Obstructive sleep apnea 03/11/2017  CONDITION ON DISCHARGE: Stable and improved PROCEDURES: None CONSULTATIONS: None  Details of Hospital Stay PRESENTING PROBLEM:  COVID-19   HOSPITAL COURSE: Patient is a 69 y.o. male with history of multiple sclerosis, smoking, hypertension and neurogenic bladder who presents with shortness of breath and cough.  Patient stated he had onset of fatigue, malaise and cough 2 weeks ago.  He reported worsening nonproductive cough, nausea, decreased appetite and dyspnea 3 days ago.  Patient lives alone and uses motorized wheelchair which he noted he spends most of the day in.  He has been having increased difficulty with transfers from bed to chair secondary to dyspnea and weakness.  Patient denied any falls, headaches, abdominal pain, diarrhea or fevers.  Due to his worsening symptoms he presented to Emergency Department for evaluation. On arrival patient?s vitals were stable.  Chest x-ray and lab work was unremarkable.  COVID-19 positive.  Troponin x2 were normal.  Patient became hypoxic at 87% on room air and was placed on 2 L oxygen per nasal cannula.  Patient received gentle hydration and 6 mg IV Decadron.  Patient continued to report generalized weakness and noted he felt unsafe to take care of himself at home.  He noted he does not have help available until Monday.  Given his history of multiple sclerosis, weakness and hypoxia he was transferred to Hospital for admission and further management of COVID-19 and hypoxia.   Patient is requesting consultation with palliative care.  Patient COVID 19 symptoms improved.  We were able to wean his oxygen down to 2 L. But he persisted with profound weakness and we contacted his neurologist for recommendations, IgG levels and vitamin-D levels were checked and came back all normal.  PT and OT re evaluation recommended subacute rehab placement.  Due to COVID restrictions, Care Management was having difficulty placing him even once he was out of respiratory isolation.  Patient eventually was removed from isolation.  He remained stable, requiring 2L of oxygen but still with significant exertional SOB and fatigue.  NIF and VC were measured and the case was discussed with his neurology provider.  It was felt he was suffering from deconditioning in the setting of his chronic MS rather than an acute flare.  Arrangements were made for SAR placement and he was accepted to rehab for further care.  He was discharged in stable condition.    PHYSICAL EXAM ON DISCHARGE:  BP 121/71  | Pulse 81  | Temp 36.3 °C (Axillary)  | Resp 18  | Ht 1.88 m  | Wt 79 kg  | SpO2 90%  | BMI 22.35 kg/m²  FIO2 (%): 28 % Physical Exam Constitutional:      General: He is not in acute distress. Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Intact distal pulses.     Heart sounds: No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No edema.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.      I have personally interviewed and examined the patient on  2/20/2022  . Management was discussed with NP. I agree with the documented findings and plan of care in his/her note.  Will continue 2 L oxygen support attempt to wean today and tomorrow after steroids have kicked in.  Also albuterol MDI may be beneficial as well as Acapella and incentive spirometry.  Patient has had symptoms over 2 weeks therefore went to severe is not initiated.     Brief exam:  Patient appears to be in no distress whatsoever however is on 2 L nasal cannula.  He is awake alert appropriate.  He has decreased bibasilar breath sounds but no rales or rhonchi at this time.  CHIEF COMPLAINT: COVID-19       ASSESSMENT/PLAN:   Principal Problem:   COVID-19 Active Problems:   Multiple sclerosis, primary progressive   Smoker   Neurogenic bladder   Cognitive dysfunction accompanying multiple sclerosis   HTN (hypertension)   Obstructive sleep apnea   Neuropathic pain  * COVID-19 Assessment & Plan Patient currently on 2L of O2 to keep sats >90% Patient noted onset of sx's 2 weeks agooutside the window for Remdesivir Dexamethasone 6 mg oral -1/10 days Continue pulse oximetry and titrate oxygen to keep sats above 90%. Wean off oxygen as able. Encourage prone positioning and incentive spirometry. Continue supportive treatment with Tylenol for fever, albuterol p.r.n. for shortness of breath and Mucinex. Monitor daily COVID labs-complete blood count, CMP, D-dimer and CRP. DVT prophylaxis: Lovenox 40 mg sq daily                       Neuropathic pain Assessment & Plan Continue home baclofen and lyrica   Obstructive sleep apnea Assessment & Plan Wears CPAP at night. Continue supplemental oxygen given COVID-19   HTN (hypertension) Assessment & Plan Continue home lisinopril and HTZD      Cognitive dysfunction accompanying multiple sclerosis Assessment & Plan Patient has delay in thinking process and verbalizing thoughts.   Neurogenic bladder Assessment & Plan Continue home oxybutynin and flomax    Smoker Assessment & Plan Current 3/4 ppd smoker Stated hasn't smoked in a few days. Also uses marijuana vape pen for sleep and help with increasing his appetite.   Multiple sclerosis, primary progressive Assessment & Plan Ocrevus (ocrelizumab) infusions, most recently infused 10/18/2021. Has a powerchair that he spends 80% of his time in. Patient noted recent difficulty with swallowing - NPO until evaluated by SLP - home dalfampridine (Generic form of Ampryra) not on hospital formulary.  - continue home Vit D, baclofen and lyrica  - PT/OT eval HISTORY OF PRESENT ILLNESS: Patient is a 69 y.o. male with history of multiple sclerosis, smoking, hypertension and neurogenic bladder who presents with shortness of breath and cough.  Patient stated he had onset of fatigue, malaise and cough 2 weeks ago.  He reported worsening nonproductive cough, nausea, decreased appetite and dyspnea 3 days ago.  Patient lives alone and uses motorized wheelchair which he noted he spends most of the day in.  He has been having increased difficulty with transfers from bed to chair secondary to dyspnea and weakness.  Patient denied any falls, headaches, abdominal pain, diarrhea or fevers.  Due to his worsening symptoms he presented to Emergency Department for evaluation. On arrival patient?s vitals were stable.  Chest x-ray and lab work was unremarkable.  COVID-19 positive.  Troponin x2 were normal.  Patient became hypoxic at 87% on room air and was placed on 2 L oxygen per nasal cannula.  Patient received gentle hydration and 6 mg IV Decadron.  Patient continued to report generalized weakness and noted he felt unsafe to take care of himself at home.  He noted he does not have help available until Monday.  Given his history of multiple sclerosis, weakness and hypoxia he was transferred to Hospital for admission and further management of COVID-19 and hypoxia. OBJECTIVE: Review of Systems Constitutional:  Positive for appetite change and fatigue. Negative for fever.  HENT: Positive for trouble swallowing. Negative for rhinorrhea and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for sputum production.   Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Positive for nausea and trouble swallowing. Negative for vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Positive for muscle pain (Chronic) and gait problem (Chronic). Negative for falls.  Neurological:  Positive for weakness. Negative for headaches and dizziness.  Psychiatric/Behavioral:  Positive for anxiety.  Skin:  Negative for rash and wound.    BP 142/86  | Pulse 73  | Temp 36.7 °C (Oral)  | Resp 20  | Ht 1.88 m  | Wt 79 kg  | SpO2 96%  | BMI 22.35 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is awake. He is not in acute distress.    Appearance: He is underweight. He is ill-appearing (Chronically).     Interventions: Nasal cannula in place.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Comments: No JVD Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rhonchi present.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No swelling or deformity. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: He is alert. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Speech: Speech is delayed.        Behavior: Behavior is cooperative.        Cognition and Memory: Cognition is impaired.