Age: 73.0
Sex: M
Vaccine: COVID19
Symptoms: Factor V Leiden mutation, Fatigue, Feeding tube user, Fibrin D dimer, Gastrointestinal sounds abnormal
Clinical narrative: Hospitalized (1.10.22 - 1.18.22); COVID-19 positive (1.6.22); Fully vaccinated --pfizer x2 d/c summary: DISCHARGE SUMMARY   BRIEF OVERVIEW Discharge Provider: MD  Primary Care Provider at Discharge: MD Admission Date: 1/10/2022 Discharge Date: 1/18/2022 Active Hospital Problems   Diagnosis Date Noted POA ? Weakness 11/16/2021 Yes ? Acute on chronic respiratory failure with hypoxia (HCC) 02/19/2021 Yes ? Factor V Leiden (HCC) 11/16/2021 Yes ? Protein-calorie malnutrition, moderate (HCC) 11/17/2021 Yes ? COVID-19 01/10/2022 Yes ? Small bowel obstruction (HCC) 12/20/2021 Yes ? Type 2 diabetes mellitus (HCC) 12/20/2021 Yes ? OSA (obstructive sleep apnea) 03/19/2009  Appointments Needing to be Scheduled DETAILS OF HOSPITAL STAY PRESENTING PROBLEM: Small bowel obstruction (HCC) [K56.609] Partial small bowel obstruction (HCC) [K56.600] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 73 y.o. male who presented with  small-bowel obstruction and COVID.  He was subsequently found to be COVID positive and did require increased oxygen requirements compared to his baseline 2.5 L. He was started on dexamethasone and has now completed the remdesivir course.  He is also able to start tolerating tube feedings and had resolution of his small-bowel obstruction symptoms.  A chest x-ray on 01/12 showed worsening bilateral airspace opacities.  He is now back to wearing his baseline 2.5 L of oxygen.  On the day of 1/17 the patient had elevated white blood cell count of 17,000 however had no other correlating symptoms such as increased oxygen requirements, cough, fever or sputum production.  The patient was attempted to be discharged however the patient's spouse was not comfortable with this at this time.  A differential showed elevated segmented neutrophils and a chest x-ray showed improvement in bilateral ground-glass airspace disease.  Patient was afebrile and hemodynamically stable.  He had no abdominal pain chest pain or productive cough.  He was discharged on 01/18/2022 in stable condition with follow-up with his primary care physician.       BP 103/61  | Pulse 83  | Temp 36.5 °C (Oral)  | Resp 20  | Ht 1.753 m  | Wt 61.6 kg  | SpO2 93%  | BMI 20.05 kg/m²  FIO2 (%): 36 % (increased per spo2 of 89%) Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. No friction rub. No gallop.   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. There is no rebound.  Musculoskeletal:        General: No deformity. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.    H&P: CHIEF COMPLAINT: Small bowel obstruction (HCC)   Assessment/Plan    ASSESSMENT/PLAN: * Small bowel obstruction (HCC) Assessment & Plan Seen in ER 1/6 with N/V and sent home with Zofran CT on 1/6 shows possible SBO vs ileus CT 1/10/2022: Dilated mid abdominal small bowel loops. Nondistended large bowel. Multiple diverticula. Gastrostomy tube tip overlies the body the stomach. Abnormal bowel gas pattern most consistent with partial small bowel obstruction.   NPO - sip and chips ok - meds via G tube G-Tube in place Consult General Surgery IV fluids: LR 100ml/hr for 24hrs Antiemetics Strict Intake and Output CBC, BMP in am   COVID-19 Assessment & Plan Date of Symptom onset: Chronicially requriing 2.5L baseline, unaware of sx until tested positive in the ED Jan 6th Date of positive COVID-19 test: 1/06/2022 Chest CT: Under aerated lungs. Patchy bilateral airspace disease redemonstrated.   Current oxygen requirement: SpO2: 95 % O2 Flow Rate (l/min): 2.5 l/min   CRP: 35.6  D-dimer: Pending Ferritin: Pending   Albuterol INH 2 puffs q 6 hours Dexamethasone - 6 mg po/IV day 1/10 Remdesivir - 200 mg IV day 1, followed by 100 mg day 2-5 DVT prophylaxis: Currently anticoagulated on Apixaban Daily CBC w/diff, CMP, CRP, D-Dimer   Type 2 diabetes mellitus (HCC) Assessment & Plan   Lab Results Component Value Date   HGBA1C 6.4 (H) 02/27/2021   Hold home injectable agents Lantus 6 units nightly - hold for now given NPO Very Low meal time and correction factor insulin scale Blood glucose checks per protocol     Weakness Assessment & Plan Secondary to poor oral intake and overall physical deconditioning given recent history of illness.    Fall precautions PT/OT Nutrition consult for tube feedings and dietary recommendations   Factor V Leiden (HCC) Assessment & Plan Currently anticoagulated on Apixaban, continue home meds.   Protein-calorie malnutrition, moderate (HCC) Assessment & Plan Consult nutrition for tube feeding management and recommendations.   OSA (obstructive sleep apnea) Assessment & Plan CPAP ordered to be utilized on autosettings if pt desires.         Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 73 y.o. male with a past medical history of factor 5 laden for which he is anticoagulated, peripheral neuropathy secondary to type 2 diabetes who presents today with abdominal pain and vomiting.  Patient was recently seen January 6 in the emergency department for abdominal pain, dry heaves.  At that time x-ray showed potential ileus or partial small-bowel obstruction.  Patient was able to be rehydrated with fluids and given Zofran and felt comfortable to return home.  At that time he did also test positive for COVID-19.  Patient chronically wears 2.5 L baseline of oxygen at home, and reports that his home nurse earlier today noted hypoxia and increased his oxygen to 3 L. Because patient stated he was continued to have nausea, abdominal pain and dry heaves with minimal relief from his prescribed Zofran, he was agreeable to returning back to the hospital to be evaluated.  Patient states he does not feel that his respiratory symptoms have increased, he does endorse feelings of weakness, fatigue and chills.  He states he has been able to tolerate oral intake for several weeks and almost all of his nutrition is via his gastric tube.  Patient does report feeling constipated but endorses a small bowel movement earlier today, which he states was loose. Patient denies presence of blood in his vomit or blood in his stool.  He is typically on a pureed diet through his G-tube but states he has little to no appetite secondary to his nausea.  Patient denies feelings of headaches, dizziness, chest pain, dysuria, hematuria.  He states he is unaware of any known COVID-19 exposures.  He was previously vaccinated.   In the emergency department patient was afebrile, tachypneic.  He wears 2-2.5 L of oxygen at baseline and was not requiring further oxygen supplementation.  Pertinent lab findings include sodium 130, consistent with poor oral intake.  Procalcitonin was within normal limits 0.09, making bacterial infection unlikely.  Lactic acid within normal limits 0.9.  EKG showed normal sinus rhythm.  Peripheral blood cultures x2 were taken.  Abdominal CT showed dilated mi abdominal small bowel loops nondistended large bowel multiple diverticula.  Abnormal gas pattern most consistent with partial small-bowel obstruction.  Chest findings include under aerated lungs, patchy bilateral airspace disease. Patient was given fluids and Zofran.  General surgery was consulted who recommended admission and medical management as patient may not be an optimal surgical candidate.  Due to concerns of small-bowel obstruction, patient was admitted to hospitalist service.   Patient is full code. Review of Systems Constitutional:  Positive for appetite change, chills and fatigue. Negative for diaphoresis and fever.  HENT: Positive for sore throat and trouble swallowing. Negative for rhinorrhea and sneezing.  Eyes: Negative for pain and redness.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing and sputum production.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea and leg swelling.  Gastrointestinal:  Positive for nausea, vomiting, abdominal pain and trouble swallowing. Negative for constipation and diarrhea.  Genitourinary:  Negative for dysuria, frequency, polyuria, hematuria and urgency.  Musculoskeletal:  Negative for neck pain, back pain, joint pain and joint swelling.  Neurological:  Positive for weakness. Negative for headaches, dizziness, loss of consciousness and numbness/tingling.  Psychiatric/Behavioral:  Negative for depression, suicidal ideas and sleep disturbance.  Skin:  Negative for itching, new spots and rash.          Objective    OBJECTIVE: BP 118/69  | Pulse 78  | Temp 36.9 °C (Oral)  | Resp 22  | Ht 1.753 m  | Wt 61.6 kg  | SpO2 94%  | BMI 20.05 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is cachectic. He is ill-appearing. He is not toxic-appearing or diaphoretic.     Comments: G tube in place  HENT:     Head: Normocephalic.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     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 friction rub. No gallop.   Pulmonary:     Effort: Tachypnea present. No respiratory distress.     Breath sounds: Decreased air movement present. No stridor. Decreased breath sounds present. No wheezing, rhonchi or rales.     Comments: Conversational dyspnea, only able to say 2-3 words at a time.  Intermittant non productive cough.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Abdomen is flat. Bowel sounds are decreased. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is abdominal tenderness (RLQ tenderness to light palpation). There is no guarding.     Comments: G tube in place  Musculoskeletal:        General: Tenderness (Lower extremity tenderness chronic neuropathy) present. No swelling or deformity. Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity or tenderness.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced or pale.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal