Age: 75.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Computerised tomogram head normal, Condition aggravated, Conjunctival hyperaemia, Contusion, Dementia
Clinical narrative: HISTORY OF PRESENT ILLNESS: Patient is a 76 y.o. male who presents with generalized weakness; he does have known dementia but still lives at home with his wife and works on his farm; mostly short-term memory issues.  Diabetes, htn, obesity, OSA other major issues.  He reportedly was doing ok 2 days ago, but yesterday and today had a couple of falls out of bed, and then could not get up off the sofa, so ultimately was brought to a local clinic.   Denies fever/chills, diarrhea, dysuria,  sob.  Maybe a mild cough.  How reliable a historian he is may be questionable.  Was found to be COVID +.   Had prior vaccination.   Other labs fairly unremarkable; mildly elevated cpk.  U/a also abnormal.  Received rocephin.  Resuscitation Status: O-DNR/DNI.   REVIEW OF SYSTEMS: A complete review of systems was negative except for that mentioned in the history of present illness   PHYSICAL EXAMINATION: Patient Vitals for the past 12 hrs:   BP Temp Pulse Heart Rate (monitor) Resp SpO2 Flow (L/min) 09/06/21 1640 157/74       09/06/21 1643 157/74 36.7 °C (98.1 °F) 81  18 93 %  09/06/21 1644    74 18 94 %  09/06/21 1646  36.8 °C (98.3 °F)      09/06/21 1647    76 21 93 %  09/06/21 1655 119/58   76 21 93 % 0 09/06/21 1659    74 20 93 %  09/06/21 1703    76 18 93 %  09/06/21 1725 129/73   74  94 % 0 No intake or output data in the 24 hours ending 09/06/21 1821 General appearance: alert, cooperative, no distress Eyes: conjunctiva red, some greenish discharge Lungs: faint crackles bases Heart: very distant tones; regular, otherwise could not comment Abdomen: (RN palpating):  soft, NT, ND; obese Extremities: bruising L elbow, redness R elbow, contusion L knee Skin: contusion/abrasions elbows/knees as above;  Neurologic: alert, oriented to person, place, but fairly vague answers otherwise   SKIN INTACT? YES   CATHETER/LINES ON ADMISSION: No urinary catheter is present on admission. No central line is present on admission.   INVESTIGATIONS: Recent Results (from the past 8 hour(s)) Lab RAPID COVID-19 Screen- Nasal Swab   Specimen: Nose/NP; Respiratory Result Value Ref Range   COVID-19 SCREEN COVID-19 Positive (A) COVID-19 Negative BUN Result Value Ref Range   BUN 19 8 - 26 mg/dL CREATININE Result Value Ref Range   CREATININE 1.08 0.67 - 1.17 mg/dL   ESTIMATED GFR 66 mL/min/1.73m2 GLUCOSE Result Value Ref Range   GLUCOSE 124 (H) 70 - 99 mg/dL ELECTROLYTES Result Value Ref Range   SODIUM 140 135 - 146 mmol/L   POTASSIUM 4.5 3.4 - 5.0 mmol/L   CARBON DIOXIDE-TOTAL 22 22 - 29 mmol/L   CHLORIDE 104 96 - 108 mmol/L   ANION GAP 14 6 - 16 mmol/L Lab Lactate sepsis with 4 hour reflex Result Value Ref Range   LACTATE SEPSIS WITH 4 HR REFLEX 1.7 Venous: 0.5 - 2.2 mmol/L CPK Result Value Ref Range   CPK 523 (H) 20 - 200 U/L LAB ETHANOL Result Value Ref Range   ETHANOL <10 <=10 mg/dL LAB ELECTRONIC CBC Result Value Ref Range   WBC 12.11 (H) 3.70 - 10.40 K/uL   RBC 4.42 (L) 4.50 - 5.80 M/uL   HEMOGLOBIN 14.6 13.6 - 16.7 g/dL   HEMATOCRIT 43.3 41.0 - 50.0 %   MCV 98.0 82.0 - 99.0 fL   MCH 33.0 (H) 27.0 - 32.0 pg   MCHC 33.7 32.0 - 36.0 g/dL   PLATELET COUNT 223 140 - 385 K/uL   RDW-CV 12.8 11.8 - 15.6 %   RDW-SD 46.4 34.0 - 50.0 fL   ABS NEUT ELECTRONIC 9.14 (H) 2.00 - 8.70 K/uL   ABS LYMPH ELECTRONIC 1.84 0.70 - 4.70 K/uL   ABS MONO ELECTRONIC 0.95 0.00 - 1.10 K/uL   ABS EOS ELECTRONIC 0.14 0.00 - 0.50 K/uL   ABS BASO ELECTRONIC 0.03 0.00 - 0.20 K/uL   ABS IMMATURE GRAN ELECTRONIC 0.01 0.00 - 0.04 K/uL Lab Procalcitonin Result Value Ref Range   Procalcitonin 0.13 <0.25 ng/mL LAB URINE Result Value Ref Range   COLOR Light Yellow Yellow, Colorless, Light Yellow, Dark Yellow   CLARITY Turbid (A) Clear, Cloudy, Slightly Cloudy   LEUKOCYTE ESTERASE 3+ (A) Negative   NITRITES Negative Negative   OCCULT BLOOD 2+ (A) Negative   SPECIFIC GRAVITY 1.020 1.005 - 1.025   KETONE Negative Negative   BILIRUBIN Negative Negative   GLUCOSE, URINE 2+ (A) Negative   ALBUMIN, URINE 1+ (A) Negative   PH - URINE 6.0 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0 LAB URINE MICROSCOPIC Result Value Ref Range   WBC, URINE >100 (H) <=5 /HPF   WBC CLUMPS Many     RBC, URINE       SQUAMOUS EPITH       BACTERIA >50 (A) None, <10 /HPF   CT scan of the head personally reviewed:  no acute abnormalities (formal read pending).   CXR personally reviewed:  No acute cardiopulm abnormalities (formal read pending)   EKG personally reviewed:  Sinus, Q waves II, III, AVF, precordial--unchanged from prior.     MEDICAL DECISION MAKING: I have personally independently reviewed and interpreted lab, cxr, ct, ekg In addition, I have reviewed and summarized old records as per the HPI.   ASSESSMENT & PLAN: Active Hospital Problems   Diagnosis   POA o COVID-19   Yes o Rhabdomyolysis   Yes o UTI (urinary tract infection)   Unknown o Dementia with behavioral disturbance (*)   Yes o Hyperlipidemia (*)   Yes o Type 2 diabetes mellitus without retinopathy (*)   Yes o Generalized weakness   Yes o Morbid obesity (*)   Yes o OSA (obstructive sleep apnea)   Yes o Hypertension (*)   Yes   COVID-19:    Symptom onset: ? 9/6/21 Date of diagnosis: 9/6/21 Date of admission at hospital:  9/6/21   Potential end of isolation:  Inpatient guidelines: 20 days since first positive test (symptomatic).9/26/21 Discharge guidelines: Per local health department.   Treated with:  Remdesivir: Dates started/completed: no indicated Dexamethasone: Dates started/completed: not indicated Antibiotics: rocephin (UTI) Anticoagulation/DVT prophylaxis: lovenox  Other: Tocilizumab/Baricitnib/Monoclonal aby not indicated   - Current O2 requirement: RA (baseline RA).  Goal SPO2 92-96% with continuous pulse oximetry.   - Self proning as tolerated   - Code status: DNR/DNI- ACP on file: (no) if not on file place ACP consult     COVID:  No significant pulmonary manifestations, hence not a candidate for covid-directed medications at this time. Likely his weakness is due to covid, vs from UTI. -PT/OT evals -supportive care   UTI:  Continue rocephin pending UC results. Check post-void residual.     Htn:  Usual meds   DM:  Hold oral meds; continue basal insulin partial dose (50 units)with high dose SSI for now.   Rhabdo:  Mild, fluid bolus and encourage oral intake of fluids.   Htn:  Hold ace pending recheck creat tomorrow, given mild rhabdo   Dementia:  Cont namenda       Patient's current Medical Level of Care is OBSERVATION.    OBSERVATION level of care is appropriate because I am NOT certain that hospital confinement (including time spent in the ED or at an outside institution prior to transfer) will be medically necessary for at least 2 midnights.