Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Laboratory test normal, Malaise, Mean cell volume increased, Myalgia
Clinical narrative: ED - 12.8.2021 -Admitted/Hospitalized (12.9.21 - 12.11.2021); COVID-19 positive (12.8.21); Fully vaccinated -moderna x2 D/c Summary: Discharge Summary (Physician) ? ? General Medicine Discharge Summary    BRIEF OVERVIEW:  Admission Date: 12/9/2021 Discharge Date: 12/11/2021   DISCHARGE DIAGNOSES: 1. Ground level fall with generalized weakness 2. COVID-19 infection 3. Right 5th distal metatarsal fracture 4. Stage 3a CKD 5. GERD 6. E. coli UTI 7. Hypothyroidism 8. Hyperlipidemia 9. Benign essential hypertension 10. Vascular dementia with mood disorder 11. Sinus node dysfunction s/p pacemaker   DISCHARGE DISPOSITION: Discharge to home   DISCHARGE CONDITION: Stable   FOLLOW-UP RECOMMENDATIONS: 1. Patient was recommended to follow-up with doctor in one week      Future Appointments Date Time Provider Department Center 4/13/2022  1:40 PM MIENTAGDVL    Appointments Needing to be Scheduled  Contact information for follow-up     MD Specialty: Family Medicine Relationship: PCP - General       Next Steps: Follow up in 3 day(s)   Instructions: As needed           Next Steps: Follow up   Instructions: accepted for home physical therapy and occupational therapy, they will call you in 1-2 days to set up initial evaluation, call them with any questions.  They will add a MSW for future planning and home health aid for bathing as well.  DETAILS OF HOSPITAL STAY:   HOSPITAL COURSE Patient is an 86-year-old male with history of stage 3a CKD, GERD, hypothyroidism, hyperlipidemia, hypertension, vascular dementia and sinus node dysfunction s/p pacemaker who presented following a fall at home.  She reportedly attended a family birthday party about a week prior to presentation, and began feeling ill on 12/06.  She reported a cough, subjective fever and myalgias.  She was becoming progressively more weak at home.  She is vaccinated with the Moderna vaccine, but has not received her booster.  On the morning of presentation, she was attempting to get out of bed when she lost her balance and fell into her dresser.  She was too weak to get up, so was brought to the emergency department for further evaluation.  In the emergency department, she was tachycardic and hypertensive.  She was not hypoxemic.  Labs were essentially unremarkable, including procalcitonin of 0.2 and WBC count of 6.4.  Urinalysis was significant for positive nitrite, moderate leukocytes, small blood, many bacteria and >50 WBCs.  Testing for COVID returned positive.  She was given 1 g of IV ceftriaxone for possible urinary tract infection and a 500 mL bolus of normal saline.  X-ray did show a fracture of the distal, 5th metatarsal of the right foot.  She was evaluated by Physical and Occupational therapy, who felt she was too weak to return home.  She was admitted to the for further care.   Upon admission, the patient remained on room air.  She did have a single fever up to 37.9° C, but was otherwise minimally symptomatic from a COVID standpoint.  She received a dose of Regeneron on 12/10, which she tolerated well.  After further discussion with family, they did not wish to pursue placement, and felt that family could help care for her at home.  Discharge plan is for her to move in with her daughter, who will assist with ADLs.   Urine culture did return with >100,000 E coli.  She was placed on IV Rocephin while hospitalized, and will be discharged on 3 days of Keflex 500 mg BID.   She was felt stable for discharge home on 12/11/2021.  She should wear a surgical shoe on the right foot when out of bed, for 5th metatarsal fracture.  She should follow-up with doctor in 1 week.  Would recommend referral to orthopedic surgery for evaluation in 2 weeks.   CONSULTS / RECOMMENDATION: None   INPATIENT PROCEDURES: None  H&P: CHIEF COMPLAINT: COVID-19 virus infection     Assessment/Plan    ASSESSMENT / PLAN: 1. GLF with associated generalized weakness -likely secondary to COVID-19 -PT/OT consult -pacemaker in place -- case discussed with EP yesterday, and pacemaker was felt to be functioning normally   2. COVID-19 infection -chest x-ray on 12/8 with no acute airspace disease -(+) COVID test on 12/8, symptoms since 12/6 -vaccinated (Moderna, 3/4 and 4/2/21); no booster -fact sheet for Regeneron provided to patient.  I contacted the monoclonal antibody team, and this has been ordered for administration.   3. Right 5th distal metatarsal fracture -surgical shoe in place -weight bearing as tolerated   4. Stage 3a CKD -Cr 0.99 today, which is baseline -monitor renal function   5. GERD -continue Protonix   6. Pyuria -UA with >50 WBCs and many bacteria -await urine culture -continue IV Rocephin (1st dose given in ED)   7. Hypothyroidism -continue Levothyroxine   8. Hyperlipidemia -change Mevacor to Lipitor per hospital formulary   9. Benign essential hypertension -continue Atenolol, Amlodipine and Hydralazine -BP elevated in ED; will monitor   10. Vascular dementia with mood disorder -dementia appears mild -continue Zyprexa 2.5 mg nightly   11. Sinus node dysfunction s/p pacemaker -noted     Code status: DNR/DNI VTE ppx: Lovenox           Subjective    HISTORY OF PRESENT ILLNESS: Patient is an 86 y.o. female with history of vascular dementia with mood disorder, hypothyroidism, hyperlipidemia, chronic hyponatremia, GERD and stage 3a CKD who presented following a fall at home.  She was seen in the emergency department yesterday after an apparent episode of syncope.  Her case was discussed with EP at that time, given her history of sinus node dysfunction with presence of pacemaker, and it was determined that her pacemaker was functioning well, and she was discharged home.  She states that she attended a family birthday party last week, and began to feel ill on 12/6.  She does not know of a direct contact to COVID, but assumes that it likely occurred at this per day party.  On Monday, she developed subjective fevers, cough and generalized weakness with myalgias.  She reports that she was vaccinated for COVID, with chart confirms occurred with Moderna on 3/4 and 4/2.  She has not received her booster.  She states that since symptom onset, she has become progressively more weak at home, to the point that she can hardly walk.  This morning, after attempting to get up from her bed, she states that she lost her balance and was too weak, falling into her dresser.  Several items that were setting on the dresser toppled off and landed on her, including a clock and a lamp.  She was too weak to get up, so was brought back to the ED for further evaluation.  In the emergency department, she was tachycardic and hypertensive.  She has been afebrile.  She has not been hypoxemic.  Labs are essentially unremarkable, including procalcitonin of 0.2, WBC count 6.4.  Urinalysis was significant for positive nitrite, moderate leukocytes, small blood, many bacteria, and >50 WBCs.  While in the emergency department, she was given 1 g IV ceftriaxone for possible UTI and 500 mL bolus of normal saline.  She was evaluated by PT and OT, but was felt to be too weak to return home.