Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Essential hypertension, Fall, Fatigue, Gait disturbance, Gastrointestinal sounds abnormal
Clinical narrative: Hospitalized (12.20.21 - 12.22.21); COVID-19 positive (12.20.21); Fully vaccinated - J&J x1 Pt left Hospital on 12/22/21 - calling PCP's office with complaints of weakness, pneumonia on 12/27/21 D/c summary: Discharge Summary  Case was reviewed and discussed. Patient wanted to leave- refused steroids. Glucose levels are quite elevated. Still requiring oxygen so will try to help set up home oxygen for her. At high risk for deterioration and needing readmission. Reminded that she can and should return to the ER if she gets worse after leaving.  Discharge Summary    BRIEF OVERVIEW:  Admission Date: 12/20/2021 Discharge Date: 12/22/2021    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 12/20/2021 Yes ? Hypoxia 12/20/2021 Yes ? CKD (chronic kidney disease), stage III  03/03/2020 Yes ? Acute kidney injury  12/21/2021 No ? Lupus (HCC) 12/20/2021 Yes ? Type 2 diabetes mellitus, without long-term current use of insulin    Yes ? Class 3 severe obesity in adult    Yes ? Essential hypertension 03/26/2021 Yes ? Coronary artery disease involving native coronary artery of native heart without angina pectoris 04/23/2020 Yes ? Hyponatremia 12/20/2021 Yes ? Dyslipidemia   Yes ? Depression   Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Sepsis (HCC) 12/20/2021 12/22/2021 Yes ? Hyperkalemia 12/21/2021 12/22/2021 Yes    Pre-Existing Active Problems   Diagnosis Date Noted POA ? ANA positive 07/29/2021 Unknown ? Ds DNA antibody positive 07/29/2021 Unknown ? Nephrotic syndrome 07/29/2021 Unknown ? Tremor 03/03/2021 Unknown ? Personal history of colonic polyps 09/08/2020 Unknown ? Chest pain 03/09/2020 Unknown ? Epigastric pain 12/10/2015 Unknown ? DJD (degenerative joint disease) of hip   Unknown ? DJD (degenerative joint disease) of knee   Unknown         Active Issues Requiring Follow-up Issue: covid 19, PNA Recommended follow-up provider/specialty: PCP What is needed: hospital follow up; oxygen management   Issue: DM Recommended follow-up provider/specialty: PCP What is needed: DM management       DISCHARGE DISPOSITION: discharged    No future appointments. Appointments Needing to be Scheduled  Contact information for follow-up            Next Steps: Follow up   Instructions: f/u asap     Specialty: Endocrinology, Diabetes and Metabolism, Internal Medicine Relationship: PCP - Diabetic Care       Next Steps: Follow up      Instructions for after discharge    Call the Doctor for Persistent Nausea or Vomiting   Complete by: As directed     Call the Doctor for Redness, Tenderness, or Signs of Infection at IV or Procedure Site(s)   Complete by: As directed     Call the Doctor for Severe Uncontrolled Pain   Complete by: As directed     Call the Doctor for Temperature Greater Than 100.3 F   Complete by: As directed     Call the Doctor if Red Blood Found in Stool or Vomit   Complete by: As directed     Diabetic Diet   Complete by: As directed     Do Not Smoke or Use Tobacco Products   Complete by: As directed     Read New Medication Instructions   Complete by: As directed     Resume Normal Activity as Tolerated   Complete by: As directed        DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 77 year old female patient with knonw history of lupus and diabetes. She had presented to the Ed with 6 days of complaints of symptoms. She was found to be hypoxic and results showed positive for COVID 19 pneumonia. There was concern for a superimposed bacterial infection. She was vaccinated for COVID 19 with the J&J vaccine in 5/2021, and overdue for her booster since 7/2021. She was admitted and started on IV steroids, remdesivir and IV antibiotics. She continued to require oxygen supplementation. Today, she complained of feeling like her arm was hurting due to the IV, which nursing has had a difficult time with IV sticks requiring ultrasound guided. Her current IV flushing well without any sign of redness. She refused steroids on day of discharge and voiced that she just wants to go home. She insisted on going home against medical advice. Risks of leaving were explained up to the possibility of death and she verbalized understanding of the risks and still insists on leaving. We will have her evaluated for home oxygen prior to discharge as she was requiring 2L n/c. We will also discharge her on antibiotics to complete a 5 day course. She was instructed to follow up with her PCP ASAP and if she worsens or not improved to return to ER. Patient verbalized understanding. Paper was reviewed with 2 RNS witnessing her agreement.     PHYSICAL EXAM: BP 159/81  | Pulse 100  | Temp 36.4 °C (Oral)  | Resp 20  | Ht 1.638 m  | Wt 113.2 kg  | SpO2 95%  | BMI 42.18 kg/m²    General:  No apparent distress. Head:  Normocephalic, atraumatic EENT:  MMM & pink. Lungs:  Respirations even & unlabored.  CTA CV:  RRR.  No murmurs, rubs, gallops.   Abd:  Soft, nontender, nondistended.  Bowel sounds normal. MS:  No deformities. Neuro:  A&O.  No gross motor or focal deficits. Psych: Agitated  H&P:  Case was reviewed and discussed.  COVID-19 viral pneumonia, likely with secondary bacterial pneumonia. AKI on CKD III and severe sepsis present. Avoid nephrotoxins and dose adjust medications. Repeat labs in am and give very gentle fluids if not improved. Agree with holding ACE-I.  Expand All Collapse All     Hide copied text  Hover for details    History & Physical    CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan     ASSESSMENT/PLAN:  * Pneumonia due to COVID-19 virus Assessment & Plan - With superimposed bacterial CAP  - Personally reviewed CXR consistent with multifocal pneumonia worse on R - Continue ceftriaxone and azithromycin for 5 day course  - Onset of symptoms: 12/14/2021 - Start remdesivir monitor renal function and LFTs closely  - Trend D-dimer and CRP - Start solumedrol 40mg Q8H as she is diminished throughout and on steroids at baseline for lupus - Encourage prone positioning and IS use       Hypoxia Assessment & Plan -Placed on 2l NC - Does not require oxygen at baseline  - Wean oxygen to maintain sats >90%   Sepsis (HCC) Assessment & Plan - Due to COVID-19 pneumonia with superimposed bacterial pneumonia  - Avoid additional IV fluid resuscitation given HD stability and COVID-19 status    Hyponatremia Assessment & Plan - Mild due to dehydration  - Received IV fluids  - Trend with AM labs    Lupus (HCC) Assessment & Plan - With nephrotic syndrome  - Takes prednisone at home - Will hold for now while on IV steroids    Essential hypertension Assessment & Plan - Pressure soft upon initial presentation  - Hold home lisinopril, propranolol and norvasc    Coronary artery disease involving native coronary artery of native heart without angina pectoris Assessment & Plan - Continue aspirin and statin    CKD (chronic kidney disease), stage III (HCC) Assessment & Plan - Renally function slightly worse than baseline - In the setting of adequate PO intake and COVID-19 will hold off additional IVF  - Trend renal function in AM, renally dose medications    Class 3 severe obesity in adult (HCC) Assessment & Plan - Increases risk of complication with underlying COVID-19  - Recommend weight loss and  outpatient follow-up    Depression Assessment & Plan - No longer taking meds for this  - Continue without patient follow-up    Dyslipidemia Assessment & Plan - Continue statin    Type 2 diabetes mellitus, without long-term current use of insulin (HCC) Assessment & Plan - Uncontrolled BG >300 upon admit  - MDSS and lantus 15 units  - POC BG AC/HS  - Monitor closely for steroid induced hyperglycemia    VTE prox: SQ lovenox  GI prox: Pepcid         Subjective     HISTORY OF PRESENT ILLNESS: Patient is a 77 y.o. female type 2 diabetes, CKD stage 3,CAD (s/p LAD on Plavix), and hypertension who presented today with cough, fever, headache, shortness of breath, and chest pain for the past 6 days. The patient reports having associated productive cough, N/V and diarrhea. She also reports falling at home, she does not use an assitive device at baseline. She lives at home alone. Denies using home oxygen or CPAP machine. The patient is vaccinated against COVID-19 (1 shot J&J). She sought care due to increased weakness and notes that she probably should have come in sooner as she has been struggling to care for herself at home over the past week.    The patient will be admitted with an expected length of stay greater than 2 midnights but less than 96 hours.      Patient Active Problem List Diagnosis ? Type 2 diabetes mellitus, without long-term current use of insulin (HCC) ? Dyslipidemia ? Depression ? Class 3 severe obesity in adult (HCC) ? DJD (degenerative joint disease) of hip ? DJD (degenerative joint disease) of knee ? Epigastric pain ? CKD (chronic kidney disease), stage III (HCC) ? Chest pain ? Coronary artery disease involving native coronary artery of native heart without angina pectoris ? Personal history of colonic polyps ? Tremor ? Essential hypertension ? ANA positive ? Ds DNA antibody positive ? Nephrotic syndrome ? Pneumonia due to COVID-19 virus ? Sepsis (HCC) ? Lupus (HCC) ? Hypoxia ? Hyponatremia    Medical History Past Medical History: Diagnosis Date ? Anemia   ? Choledocholithiasis 12/23/15   ERCP ; post proc pancreatitis ? CKD (chronic kidney disease), stage III    ? Coronary artery disease   ? Depression   ? Diabetes mellitus   ? Diabetes mellitus type 2, noninsulin dependent (HCC)     denies complications ? DJD (degenerative joint disease) of hip     left replaced ? DJD (degenerative joint disease) of knee     bilateral TKA's ? Dyspnea on exertion   ? Former smoker   ? GERD (gastroesophageal reflux disease) 8/17/11 ? Hard of hearing   ? High cholesterol   ? History of colon polyps   ? History of sexual abuse   ? Hypertension   ? Hypothyroidism   ? Lupus   ? Morbid obesity   ? Personal history of colonic polyps 9/8/2020 ? Stented coronary artery 03/18/2020   DES x1 to LAD     Past Surgical History Past Surgical History: Procedure Laterality Date ? HX CARDIAC CATHETERIZATION   03/18/2020   DES to LAD ? HX COLONOSCOPY   6/16/10   Coates, polyps, repeat 5 yrs ? HX COLONOSCOPY   7/25/14   DAJ, neg ? HX COLONOSCOPY   09/08/2020 ? HX COLONOSCOPY   9/8/2020 ? HX CORONARY STENT PLACEMENT   03/18/2020   LAD ? HX ERCP   12/23/15    ? HX GASTROPLASTY   1978   stomach stapling 1982- gastric bypass ? HX HEART CATHETERIZATION   02/08/2010   2/10 ok ? HX HIP REPLACEMENT Left 2/9/10    ? HX KNEE ARTHROSCOPY   1990; 2002   Right; Left ? HX KNEE REPLACEMENT Bilateral 12/1/04 ? HX LUMBAR LAMINECTOMY   1/12/06   L4-L5; herniated disc ? HX OF BACK SURGERY     ? HX OPEN CHOLECYSTECTOMY   1969 ? HX TAH AND BSO   1967 ? US BIOPSY THYROID FINE NEEDLE ASPIRATE   5/4/2021      Prescriptions Prior to Admission (Not in a hospital admission)    Allergies Allergen Reactions ? Amaryl [Glimepiride] GI Upset     Weight gain    Social History     Socioeconomic History ? Marital status: Divorced     Spouse name: Not on file ? Number of children: 3 ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Occupation: retired truck driving Tobacco Use ? Smoking status: Former Smoker ? Smokeless tobacco: Never Used ? Tobacco comment: quit 12-13 years ago Vaping Use ? Vaping Use: Never used Substance and Sexual Activity ? Alcohol use: Yes     Alcohol/week: 0.0 standard drinks     Comment: wine occasionally, 3x per year ? Drug use: Never ? Sexual activity: Not on file Other Topics Concern ? Military Service No ? Blood Transfusions Yes     Comment: uncertain ? Caffeine Concern Yes     Comment: 2 glasses of Iced Tea daily, coffee occasionally, no pop ? Occupational Exposure No ? Hobby Hazards No ? Sleep Concern Yes     Comment: snores ? Stress Concern No ? Weight Concern Yes ? Special Diet No ? Back Care Not Asked ? Exercise No     Comment: nothing regular due to the heat ? Bike Helmet Not Asked ? Seat Belt Yes ? Self-Exams Not Asked Social History Narrative   Lives alone with two dogs    Social Determinants of Health    Financial Resource Strain: Low Risk  ? Difficulty of Paying Living Expenses: Not hard at all Food Insecurity: No Food Insecurity ? Worried About Running Out of Food in the Last Year: Never true ? Ran Out of Food in the Last Year: Never true Transportation Needs: No Transportation Needs ? Lack of Transportation (Medical): No ? Lack of Transportation (Non-Medical): No Physical Activity: Inactive ? Days of Exercise per Week: 0 days ? Minutes of Exercise per Session: 0 min Stress: Not on file Social Connections: Unknown ? Frequency of Communication with Friends and Family: More than three times a week ? Frequency of Social Gatherings with Friends and Family: More than three times a week ? Attends Religious Services: Not on file ? Active Member of Clubs or Organizations: Not on file ? Attends Club or Organization Meetings: Not on file ? Marital Status: Divorced Housing Stability: Not on file     Family History Family History Problem Relation Age of Onset ? Coronary Artery Disease Father   ? Diabetes Father   ? Heart Failure Father         CHF ? Heart Attack Father   ? Hypertension Mother   ? Diabetes Mother   ? Alzheimers Mother   ? Pacemaker Mother   ? Colon Cancer Maternal Uncle   ? Dementia Cousin          ? Dementia Cousin          ? Dementia Cousin         ? Dementia Paternal Grandfather         with all brothers and sisters; son (pt's father) did not have it    Review of Systems Constitutional:  Positive for appetite change, chills, diaphoresis, fatigue and fever. Negative for unexpected weight change.  HENT: Negative for congestion and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, wheezing, shortness of breath, chest tightness and sputum production.   Cardiovascular:  Positive for chest pain. Negative for palpitations, orthopnea and leg swelling.  Gastrointestinal:  Positive for nausea, vomiting and diarrhea. Negative for abdominal pain and constipation.  Genitourinary:  Negative for difficulty urinating, dysuria, frequency, hematuria and urgency.  Musculoskeletal:  Positive for gait problem and falls.  Neurological:  Positive for weakness. Negative for headaches and dizziness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression.  Skin:  Negative for rash and wound.          Objective     OBJECTIVE: BP 137/61  | Pulse 68  | Temp 98.2 °F (36.8 °C) (Oral)  | Resp 20  | Wt 116.9 kg (257 lb 11.5 oz)  | SpO2 97%  | BMI 42.89 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is ill-appearing. She is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic.     Ears:     Comments: Hard of hearing  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  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: Wheezing present.     Comments: Diminished throughout, on 2L NC Chest:     Chest wall: No tenderness.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.     Comments: Hypoactive bowel sounds   Musculoskeletal:        General: No tenderness.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal