Age: 90.0
Sex: M
Vaccine: COVID19
Symptoms: Agitation, Anaemia, Anticoagulant therapy, COVID-19, COVID-19 pneumonia
Clinical narrative: Narrative: ADMISSION DATE: 9/10/21 DISCHARGE DATE: 9/14/21 DISCHARGE TYPE: regular PRINCIPAL DIAGNOSIS (Reason for admission after study): Acute hypoxic respiratory failure: Secondary to COVID-19 viral pneumonia ADDITIONAL DIAGNOSES: Acute SARS-CoV-2 pneumonia Acute-on-chronic anemia -multiple myeloma Type II Non-ST segment elevation myocardial infarction - demand ischemia. . Acute kidney injury on Stage 3a chronic kidney disease urinary tract infection due to e faecalis Acute exacerbation of combined systolic & diastolic congestive heart failure Acute metabolic encephalopathy -Multifactorial Elevated D-dimer Likely due to acute-on-chronic renal failure and acute COVID-19 infection Hypertension Type II diabetes mellitus History of atrial flutte Benign prostate hyperplasia Vitamin D deficiency Open angle glaucoma Allergic rhinitis Constipation Chronic depression HISTORY OF PRESTENT ILLNESS: from admission note 90 yr old MALE with complaints of: unable to eat or drink, fever, further deterioration in mental status Patient unable to provide history, was able to make contact with daughter to gather information and discuss assessment and plan. HISTORY OF PRESENT ILLNESS: Patient is a 90 year old male who lives with his children, daughters usually during the day and son overnight. He was recently discharged from Facility on 8/25/21. Per daughter his overall health status has been going downhill since January of this year. With each hospitalization she feels like she loses more of him that is not coming back. They have 4 siblings total but her and one brother do most of the care giving and split up days and nights. The nights have been particularly bad lately with confusion, agitation, and irritability related to needing to use the bathroom. Over the past few days this has been worse. He also developed a cough, looked short of breath at times and had a fever and chills. He has not been eating or drinking anything they bring to him but he did continue to take all of his oral medications they handed him. No vomiting, no complaints of nausea per daughter. Roughly a few days ago he was diagnosed with UTI and treated with po antibiotics but had no improvement with treatment, appeared to only be declining so he was brought back to the ED where he was found to be positive for COVID. PAST MEDICAL HISTORY: -HTN -Prostate cancer -DM (A1c 4.9 on 8/5/21)- CHF s/p AICD/PM (2015) -A. flutter s/p ablation -Nonischemic cardiomyopathy- HLD -Allergic rhinitis FAMILY HISTORY: unable to obtain SOCIAL HISTORY: Alcohol: denies Illicit drug use: denies Tobacco use: denies SURGICAL HISTORY: Cholecystectomy ALLERGIES: Travospot ROS: Unable to obtain, patient would occasionally answer yes and no but he would give both answers to the same question if asked separately at times. PHYSICAL EXAM: VITAL SIGNS: HEIGHT: 70 in [177.8 cm] (08/11/2021 21:06)inches WEIGHT: 132.782 lb [60.4 kg] (09/10/2021 01:35) TEMPERATURE: 99.2 PULSE: 60 BLOOD PRESSURE: 125/66 RESPIRATION: 18 PAIN: 0 GENERAL: lethargic but easily aroused, in NAD, disoriented x 3 HEAD: NC/ AT EARS/NOSE/THROAT: dry mucous membranes NECK: supple no nuchal rigidity LUNGS: non-labored, no conversational dyspnea on talking, some scattered wheezing, no rhonchi, no rales CARDIOVASCULAR: RRR no M/R/G ABDOMEN: soft, no grimacing with palpation EXTREMITIES: no edema NEUROLOGICAL: no obvious focal deficits no facial asymmetries, moving all 4 ext. around well, even punching and kicking at staff with all extremities without any stroke symptoms visualized HOSPITAL COURSE: Pt admitted to the SDU - dx COVID - unable to use remdesivir due to aki. sats doing well w/o use of supplemental oxygen. started on dexamethasone due ot wheezing. noted Troponinema - monitored. no acute findings on ekg, started on heparin drip. elevated d dimer pending vq scan. monitored h/h due to anemia with myeloma. tx for uti. no active bleeding noted. id consulted - currently not a candidate for sarilumab or baricitinib due to his likely immunocompromised state with his underlying MM. cardiology consulted. nothing further to add to tx. pt is completely paced at time. Limited V/Q scan shows no perfusion defects. Encephalopathy - improved today. multifactorial due to UTI/AKI/COVID infection and ? underlying cognitive impairment. 9/11 stable for transfer to the floor. pt doing well off oxygen. 9/13 hgb declined to 5.9. consent from family obtained for blood transfusion. pt tolerated procedure well. transfused 2 units PRBC. hgb improved to 8.2. pt stable for discharge to home on 9/14/21. cont tx wiht po meds for uti e faecalis.