Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Computerised tomogram head normal, Cough, Differential white blood cell count abnormal, Dizziness, Eosinophil count decreased
Clinical narrative: Hospitalized (4.7.22 - 4.9.2022); COVID-19 positive (4.7.22); fully vaccinated PLUS Booster - pfizer x3 D/c Summary:Discharge Summary   BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: MD   Admission Date: 4/7/2022 Discharge Date: 4/8/2022   Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 04/08/2022 Yes ? Osteoarthritis 09/02/2015 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Toxic encephalopathy 04/08/2022 04/09/2022 Unknown ? Generalized weakness 04/07/2022 04/09/2022 Yes ? AMS (altered mental status) 04/08/2022   DISCHARGE DISPOSITION: Home with services - Nursing   Appointments Needing to be Scheduled 1) COVID 19  patient instructed to get home pulse ox and notify primary care physician or return to ER if below 90%.  Patient is to finish his course of paxlovid.   2) toxic encephalopathy Resolved.  Was evaluated for stroke and tele Stroke not showing any acute infarct but history of infarct and neurology recommended 81 mg of aspirin and 20 mg of Lipitor as secondary stroke prevention. 3) placed on aspirin and Lipitor Writer had a long discussion with patient regarding aspirin and Lipitor.  Patient states that he is not allergic to aspirin.  Writer reviewed risk and benefits of aspirin including bleeding bruising risk and if he noticed any bright red blood or dark stools is to call   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Weakness [R53.1] Generalized weakness [R53.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 86 y.o. male who presented to the emergency department with complaints of generalized weakness. . Patient presents to emergency department in the morning of 04/07/2022 with complaints of unable to perform ADLs independently.  After workup, patient was found to be positive for COVID-19.  CT of the head showed no acute intracranial abnormalities.  Chest x-ray did show bibasilar subsegmental atelectasis.  Patient was discharged with a prescription for Paxlovid and instructions to return with worsening symptoms.  He returned in the evening with complaints of increased weakness and inability to ambulate independently.  In the emergency department, patient was hypertensive, however, other vital signs are stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  Suspect increased weakness secondary to COVID-19.     A stroke code was called as patient was leaning to the right with PT OT.  And H was 3.  CT CTA as an MRI did not show any acute process.  Patient did well and the following day was at baseline.  NIH was 0. The patient was sitting in his chair eating breakfast.  He was able to walk independently.  His weakness had resolved and his altered mental status the day before was thought to be secondary to toxic encephalopathy secondary to COVID-19.  Questions and concerns addressed.  Patient was counseled to come back to the ER if he had any new or worsening symptoms.  Patient was comfortable with this plan. Active Issues Requiring Follow-up 1) COVID-19 --patient advised to get home pulse ox and monitor oxygen saturation and notify primary care physician return to ER if below 90%.  Patient is to finish plaxlovid. 2) secondary stroke prevention Neurology did recommend aspirin and 20 mg of Lipitor.  Patient states that he was not allergic to aspirin.  Patient counseled on the risks and benefits of taking aspirin and Lipitor.  Patient was agreeable.   CONSULTS / RECOMMENDATION: IP CONSULT TO CARE MANAGEMENT IP TELEMEDICINE CONSULT   INPATIENT PROCEDURES: Surgery and Procedures    None OBJECTIVE:   BP 143/66  | Pulse 51  | Temp 36.2 °C (Oral)  | Resp 18  | Ht 1.753 m  | Wt 91.8 kg  | SpO2 95%  | BMI 29.87 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: He is alert.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.   H&P:  CHIEF COMPLAINT: Generalized weakness ASSESSMENT / PLAN: COVID-19 Assessment & Plan Patient presents to emergency department in the morning of 04/07/2022 with complaints of unable to perform ADLs independently.  After workup, patient was found to be positive for COVID-19.  CT of the head showed no acute intracranial abnormalities.  Chest x-ray did show bibasilar subsegmental atelectasis.  Patient was discharged with a prescription for Paxlovid and instructions to return with worsening symptoms.  He returned in the evening with complaints of increased weakness and inability to ambulate independently.  In the emergency department, patient was hypertensive, however, other vital signs are stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  Suspect increased weakness secondary to COVID-19.     -routine vital signs -titrate oxygen to maintain saturation greater than 90% -not a candidate for dexamethasone at this time -not a candidate for IV remdesivir this time -continue Paxlovid -incentive spirometry and cough and deep breathe -prone positioning while asleep -a.m. labs complete blood count, CMP, CRP D-dimer  Generalized weakness Assessment & Plan Patient states that he has been unable to rise or get out of bed without significant assistance.  At baseline, patient is able to walk with a cane.  Currently unable to ambulate independently.  Generalized weakness likely secondary to COVID-19. -PT and OT to evaluate patient and make recommendation -care management consulted for discharge planning   Osteoarthritis Assessment & Plan Analgesics available for pain p.r.n. Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 86 y.o. male who presented to the emergency department with complaints of generalized weakness.  Patient has a past medical history of Boca hernia, bilateral hearing loss, CVA, BPH, and arthritis. Patient presents to emergency department in the morning of 04/07/2022 with complaints of unable to perform ADLs independently.  After workup, patient was found to be positive for COVID-19.  CT of the head showed no acute intracranial abnormalities.  Chest x-ray did show bibasilar subsegmental atelectasis.  Patient was discharged with a prescription for Paxlovid and instructions to return with worsening symptoms.  He returned in the evening with complaints of increased weakness and inability to ambulate independently.  In the emergency department, patient was hypertensive, however, other vital signs are stable.  He did not require supplemental oxygen.  Complete blood count and BMP were unremarkable.  Suspect increased weakness secondary to COVID-19.  Patient has been admitted for further evaluation and management of generalized weakness secondary to COVID-19. Review of Systems Constitutional:  Positive for appetite change and fatigue. Negative for chills and fever.  HENT: Positive for rhinorrhea and sore throat. Negative for sneezing.  Eyes: Negative. Negative for light sensitivity.  Respiratory:  Positive for cough. Negative for shortness of breath.   Cardiovascular:  Negative. Negative for chest pain.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative. Negative for difficulty urinating, urinary incontinence and flank pain.  Musculoskeletal:  Negative for neck pain, back pain and joint pain.  Neurological:  Positive for headaches, dizziness and weakness.  Psychiatric/Behavioral:  Negative.  Skin:  Negative. Negative for itching, changed spots and rash.   OBJECTIVE: BP 137/68  | Pulse 65  | Temp 37 °C (Oral)  | Resp 21  | Wt 94 kg  | SpO2 95%  | BMI 30.60 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is not ill-appearing or diaphoretic.  HENT:     Head: Normocephalic.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard.   No gallop.  Pulmonary:     Effort: Tachypnea present. No respiratory distress.     Breath sounds: No wheezing or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No tenderness or signs of injury. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No erythema or rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Attention and Perception: Attention normal.        Mood and Affect: Mood normal.        Speech: Speech normal.        Behavior: Behavior normal. Behavior is cooperative.