Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Decreased activity, Decreased appetite, Fall, Fatigue, Gait disturbance
Clinical narrative: Hospitalized (5.26.22 - 5.28.22); COVID-19 positive (5.26.22);  fully vaccinated PLUS Booster - moderna Hospitalist D/C Summary: BRIEF OVERVIEW: Discharge Provider: Primary Care Provider at Discharge: Admission Date: 5/26/2022; Discharge Date:  5/28/2022; Active Hospital Problems; Diagnosis- Date Noted- POA; COVID-19    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 [U07.1]; Weakness [R53.1]; HOSPITAL COURSE: The patient is a 73-year-old female with a history of essential hypertension, diabetes mellitus type 2, overactive bladder/interstitial cystitis, hypothyroidism, CKD stage 3, who presented with increasing fatigue on 5/26 after having a ground level fall at home.  Patient did report having nasal congestion but with sore throat and cough approximately 1 week prior to admission.  In the emergency department she was found to be positive for COVID.  Chest x-ray was clear.  O2 saturation was stable on room air.  Laboratory studies showed no leukocytosis and CRP was minimally elevated at 17.3.  The patient was treated with supportive care, with Tessalon Perles and guaifenesin.  She was seen by PT/OT who felt that she was stable for discharge to home with home health care.  Referrals were made, the patient was accepted by bed home care. Patient's cough did improve with symptomatic treatment, and as the patient was otherwise clinically stable, she was discharged to home on 05/28/2022. PHYSICAL EXAM: BP 143/63  | Pulse 72  | Temp 37 °C (Oral)  | Resp 16  | Ht 1.676 m  | Wt 103 kg  | SpO2 98%  | BMI 36.65 kg/m²    Physical Exam: Vitals and nursing note reviewed. Constitutional: General: She is not in acute distress. Appearance: She is well-developed. She is obese. HENT: Head: Normocephalic. Mouth/Throat: Mouth: Mucous membranes are moist. Pharynx: No oropharyngeal exudate. Eyes: Conjunctiva/sclera: Conjunctivae normal. 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: Normal breath sounds. No wheezing. Abdominal:  General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion and neck supple. Right lower leg: No edema. Left lower leg: No edema. Skin: General: Skin is warm. Findings: No rash.  Neurological:   Mental Status: She is alert and oriented to person, place, and time. H&P: CHIEF COMPLAINT:    Generalized weakness: ASSESSMENT / PLAN: Generalized weakness -Nonfocal, likely exacerbated by COVID-19 infection-replete K/mag/phos prn -PT/OT appreciated -up to chair and mobilize as tolerated; COVID-19 upper respiratory infection, no pneumonia -CXR clear with no hypoxemia -daily CRP, minimally symptomatic -defer remdesivir at this time -continuous pulse ox -date of symptom onset approx 7 days prior to admission -defer remdesivir for now given mild symptoms in a lower risk patient, consider tomorrow if not improving -no steroid indication without hypoxemia- Old RBBB-EKG noted last year; Troponin elevation -secondary to myocardial injury in setting of covid infection -trend flat, no ischemic changes on ekg- Hypothyroidism -TSH WNL 4/29/22, clinically euthyroid -continue home synthroid- CKD3 -appears at baseline -daily bmp monitoring; Overactive bladder/interstitial cystitis -myrbetriq nonformulary -can add oxybutinin if unable to obtain home med -follows with Urology Recurrent UTI -on chronic trimpex prophylaxis Chronic estradiol use -pt attributes this to H/o hysterectomy for endometriosis, unclear if BSO  -continue estrace daily- HTN -stable -home med list includes losartan-hctz and triamterene-hctz, confirmed with patient -place both on hold given normotension and decreased po intake T2DM -oral regimen: januvia, sulfonylurea  Corrective insulin for now Diet: diabetic dvt px: SQ lovenox- Code: full, discussed upon admission HISTORY OF PRESENT ILLNESS: A 73 y.o. female who presents today with weakness. She has had symptoms for about one week but these have been worsening in the past 1-2 days, including nasal congestion (acute on chronic with alelrgies), nausea, anorexia, weakness. Today she slid out of her bed (no head trauma or loc) due to weakness and presented to the ED. She was about to be discharged from the ED but was unable to ambulate so is being brought in her for observation status. CXR was clear. She was given normal saline in the ED. Currently she states she can try eating and drinking at this time. Cough is not bothersome. Nose is chronically 'stuffed' from allergies. Review of Systems Constitutional:  Positive for activity change and appetite change. Negative for chills, diaphoresis and fever. HENT: Positive for congestion, rhinorrhea and sneezing.  Respiratory:  Positive for cough. Negative for wheezing, shortness of breath, chest tightness and sputum production.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea, claudication and leg swelling.  Gastrointestinal:  Positive for nausea and vomiting. Negative for abdominal pain, constipation, diarrhea and fecal incontinence. Genitourinary:  Negative for difficulty urinating, urinary incontinence and dysuria. Musculoskeletal:  Positive for gait problem. Negative for back pain, joint pain and joint swelling. Neurological:  Positive for weakness. Negative for headaches, dizziness, light-headedness and numbness/tingling. Psychiatric/Behavioral:  Negative for depression and anxiety. Skin:  Negative for itching and pallor OBJECTIVE: BP (!) 135/49  | Pulse 98  | Temp 37.2 °C (Oral)  | Resp 20  | SpO2 97%; Physical Exam Constitutional: General: She is not in acute distress. Appearance: She is obese. She is not ill-appearing, toxic-appearing or diaphoretic. HENT: Head: Normocephalic. Nose: Congestion present. Mouth/Throat: Mouth: Mucous membranes are moist. Eyes: General: No scleral icterus. Extraocular Movements: Extraocular movements intact. Pupils: Pupils are equal, round, and reactive to light. Cardiovascular:  Rate and Rhythm: Normal rate and regular rhythm. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: No wheezing or rales. Abdominal: General: There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. There is no guarding. Musculoskeletal: General: No swelling. Cervical back: No rigidity. Right lower leg: No edema. Left lower leg: No edema. Neurological:  Mental Status: She is alert and oriented to person, place, and time. Cranial Nerves: No cranial nerve deficit.  Motor: Weakness (mild generalized weakness in all extremities) present. Coordination: Coordination normal.  Deep Tendon Reflexes: Reflexes normal. Psychiatric: Mood and Affect: Mood normal.