Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Hypomagnesaemia, Hypophagia, Hypophosphataemia, Hypoxia, Ketosis
Clinical narrative: Hospitalized (12.26.21);  COVID-19 positive (12.27.21); fully vaccinated  Admission Date: 12/26/2021 Discharge Date: 01/03/2022 Admitting Diagnoses: Hypokalemia Details of Hospital Stay PRESENTING PROBLEM:  Hypokalemia [E87.6] Hypomagnesemia [E83.42] Ketosis  [E88.89] Failure to thrive in adult [R62.7] Syncope, unspecified syncope type [R55] Vomiting, intractability of vomiting not specified, presence of nausea not specified, unspecified vomiting type [R11.10] COVID-19 [U07.1] HOSPITAL COURSE: * Hypokalemia Assessment & Plan Potassium levels stable.  Monitor daily.  Continue IV fluids with potassium supplements. COVID-19 Assessment & Plan:  - stable and in no respiratory distress, sating 100% on room air  - Unclear symptom onset, likely >2 weeks ago - Continue mucinex for sputum production  - Supportive care  - If becomes hypoxic would add decadron   Type 2 diabetes mellitus without complication, without long-term current use of insulin  Assessment & Plan: Blood sugars have been stable without insulin coverage because of his poor intake.  Now that he is unable to keep anything down we will continue serial Accu-Cheks but once he is being fed via G-tube this will need to be readdressed.  Falls frequently Assessment & Plan: - PT/OT eval - Currently recommending SAR placement  Hypophosphatemia Assessment & Plan: Stabilizing;  Phosphorus up to 1.7; Will re-dose Sodium phosphate 40 meq x 1 recheck phos in am Essential hypertension Assessment & Plan: Patient's blood pressure is stable off antihypertensives; - Hold lisinopril and norvasc  HAP (hospital-acquired pneumonia) Assessment & Plan Patient developed a marked increase in his white count up to 14,000 and a procalcitonin was elevated at 0.65.  He developed hypoxia last night requiring up to 3.5 L but that has been weaned to room air today.  Two-view chest x-ray showed a left lower lobe infiltrate and he was started empirically on cefepime due to this being his 7th day in the hospital.  He has been afebrile and has not been coughing or hypoxic since last night.  Blood cultures were taken prior to antibiotic therapy and RT was requested to induce a sputum if possible. Ketosis  Assessment & Plan: Resolved.  Related to malnutrition and possibly alcoholic ketosis - Supportive care, encourage continued ETOH cessation   Intractable vomiting with nausea Assessment & Plan Patient continues with intractable vomiting.  Not much nausea at this point more regurgitation due to inability to swallow.  Plan consultation with General surgery/Interventional Radiology on Monday for options for feeding tube placement Protein-calorie malnutrition, severe  Assessment & Plan:  Reports 40 pound weight loss over the past year. Has difficulty with swallow, large pills need to be crushed. Reports history of esophageal dilitation. Reports epigastric pain with swallow. RN noted patient chewing food and spitting it out.  If this does not improve plan pursue of PEG tube placement - Dietitian consult - Ensure clear with meals (patient preference over milk based ensure) - dental soft diet - up in chair for meals - speech therapy recommendations: Impressions/Recommendations Swallow Diagnosis: pharyngoesophageal phase dysphagia,other (see comments) (suspected esophageal dysphagia) Diet Recommendations: thin liquids, liquids via cup and straw Strategies required for safe oral intake: upright for 60+ following meals,other (comment),small bites,small sips,slow rate (GERD Precautions), self fed, patient is independent, no specific recommendations,provide 6 smaller meals throughout day, patient independent Medication Intake Recommendation: Crushed in puree,Per patient preference    Patient unable to keep anything down at this point.  He had improved somewhat yesterday and the hope was that he could stabilize enough for discharge but that does not appear likely at this point.  Plan consultation general surgery/Interventional Radiology Monday to explore placement of a feeding tube. Severe alcohol abuse disorder with alcohol dependence  Assessment & Plan:  No evidence of withdrawal at this point; Convert to a Flintstones chewable daily Hypomagnesemia Assessment & Plan:  Magnesium level stabilizing.  Continue to monitor serially; 1.8 this morning  Weakness Assessment & Plan:  See plan under frequent falls. Complicated by chronic back pain and intermittent leg numbness. Opioid type dependence, continuous  Assessment & Plan:  Unable to keep even Hycet down due to regurgitation.  Morphine 2 mg q.4 hours p.r.n. added IV - lidocaine patch for left rib pain has been effective