Age: 94.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Mucosal dryness, Pain, Renal impairment, Respiratory failure, SARS-CoV-2 test positive
Clinical narrative: Narrative:  History of Present Illness Patient is a 94-year-old male with past medical history of CAD, CABG, hypertension, COPD on 4 L chronic O2 presenting to the emergency department today for evaluation of generalized weakness. Patient states that for the past 4 to 5 days, he has had generalized body aches and cough. He states that he had a home caregiver who recently tested positive for Covid just prior to onset of his own symptoms. He was tested 2 days ago and was positive. He states that he feels particularly fatigued and is unable to get around home to take care of himself due to the weakness and illness at this time. He denies any fevers. He states that he is not any more short of breath than normal and is most concerned about his weakness and fatigue. Does complain of generalized body aches. He has not taken anything for this. He has no complaints of any abdominal pain, nausea or vomiting. He has no other complaints at this time. Emergency department course: Patient came in for generalized weakness and fatigue in the setting of active COVID-19 infection. Initial vitals stable. On physical exam, he is in no significant distress. He does appear mildly tachypneic though states that he is not breathing any differently than normal. He has dry oral mucosa though otherwise exam is quite nonfocal. Patient was given IV fluids and Tylenol for complaints of body aches, which did improve slightly. Labs without significant leukocytosis or anemia. Electrolytes overall stable with only slight increase in his kidney function. Troponin negative. Chest x-ray and EKG performed and patient does have evidence of infiltrates consistent with COVID-19 infection. I discussed all findings with the patient as well as plan for disposition. As patiently currently lives in an independent living facility with home care, I did discuss the case with case management and unfortunately the patient's home care organization is unable to provide another worker for him. His facility is unable to provide any additional services otherwise. Patient's family is also unable to help with any of his care at this time and feel that he needs an increased level of care than he is currently getting. Based on this, I did discuss admission with the patient and he was agreeable. I discussed the case with hospitalist team, who accepted the patient for further care and management. As per 9/6/21 H&P Assessment and Plan Diagnosis: Acute COVID-19 (ICD10-CM U07.1, Working, Diagnosis). acute covid 19 infection chronic hypoxic respiratory failure hx COPD, BPH, bilateral carotid artery stenosis, hypertension, CAD status post CABG/PCI Order for monoclonal antibodies been placed in the emergency department Currently he does not meet criteria for prednisone or remdesivir therapy, his respiratory status is unchanged, he is on his baseline oxygen requirements and even saturating 93% on room air, he has no defined opacities on chest x-ray Continue supportive care with Tyelnol, albuterol as needed, home inhalers, and home medications Consult case management for placement options DVT prophylaxis with heparin subcu