Age: 76.0
Sex: M
Vaccine: COVID19, FLUA4, COVID19
Symptoms: Acute kidney injury, Acute respiratory failure, Anion gap, Anticoagulant therapy, Appetite disorder
Clinical narrative: Hospitalized (5.5.22 - 5.8.22); COVID-19 positive (5.5.22); fully vaccinated PLUS Booster - pfizer x3 Hospitalist Discharge Summary   BRIEF OVERVIEW: Discharge Provider: PA-C Attending Physician:  MD Primary Care Provider at Discharge: DO  Admission Date: 5/5/2022 Discharge Date: 05/08/2022  DISCHARGE DISPOSITION: Home without services  Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 05/06/2022 Yes ? Acute respiratory insufficiency 05/06/2022 Yes ? Generalized weakness 05/06/2022 Yes ? AKI (acute kidney injury)  05/06/2022 Yes ? Leukocytosis 05/06/2022 Yes ? History of ischemic stroke without residual deficits   Yes ? Essential hypertension 12/19/2016 Yes ? Dyslipidemia   Yes ? Major depression, recurrent, chronic    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory insufficiency [R06.89] COVID [U07.1] HOSPITAL COURSE: Patient is a 77-year-old male with a history of remote ischemic stroke without residual deficits, hyperlipidemia, GERD, depression, and anxiety who presented secondary to severe worsening generalized weakness.  About 5 days prior to admission, he began to notice worsening weakness, along with a mild cough, sore throat, shortness of breath on exertion, diarrhea, nausea, and vomiting.  He had received his COVID vaccination x2 and 1st booster in 10/2021.  On arrival, he was febrile and tachycardic.  He desatted on room air and was placed on 2 L nasal cannula.  Labs notable for leukocytosis, acute kidney injury, and COVID positive.  Chest x-ray clear.  He was given 1 L of normal saline, started on Decadron and admitted for further care.  Procalcitonin elevated at 13 for which he was started on a ceftriaxone and azithromycin.  Supplemental oxygen weaned to room air.  Additional fluids held on admission given COVID positive status, but creatinine down trended to baseline with encouragement of oral intake. OT evaluated and recommended discharge home.  He was discharged home in stable condition on 5/8/22.  He will complete a 5 day total course of antibiotics with remaining 2 days of Ceftin and azithromycin.  He was advised to arrange hospital follow-up with his primary care physician. CONSULTS: none INPATIENT PROCEDURES: none  PHYSICAL EXAM: BP 129/95  | Pulse 69  | Temp 36.7 °C (Oral)  | Resp 22  | Ht 1.626 m  | Wt 80.7 kg  | SpO2 96%  | BMI 30.54 kg/m²    Physical ExamVitals and nursing note reviewed.  Constitutional:     General: He is not in acute distress.    Appearance: He is well-developed and well-nourished.  HENT:    Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Oropharynx is clear and moist. Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Neck:    Vascular: No JVD.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:    General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:    Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:   General: Skin is warm and dry.  Neurological:    Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:       Mood and Affect: Mood and affect and mood normal.        Behavior: Behavior normal.   H&P:CHIEF COMPLAINT           "I have never felt so weak" ASSESSMENT Principal Problem:   Acute respiratory insufficiency Active Problems:   Dyslipidemia   Major depression, recurrent, chronic     Essential hypertension   History of ischemic stroke without residual deficits   COVID-19   Generalized weakness   AKI (acute kidney injury)     Leukocytosis PLAN  Acute respiratory insufficiency 2nd COVID-19 infection COVID-19 positive SIRS, second to above          Desatted to high 80s on room air, currently on 2 L nasal cannula          He is vaccinated with Pfizer x2 plus booster in 10/2021          Hemodynamically stable at this time but will need close inpatient monitoring as he is at high risk for deterioration given his increased supplemental oxygen requirements          Continuous pulse oximetry          Wean oxygen as able, aim for O2 sats > 90%          Given supplemental O2 requirements, we will start orally Decadron 6 mg daily          Inhalers p.r.n.          If patient desaturates further and renal function improves, would start remdesivir          Leukocytosis          Likely 2nd to COVID-19 infection          Doubt bacterial coinfection so will hold off on antibiotics at this time          Procalcitonin pending, if positive would start CAP coverage with IV ceftriaxone and azithromycin  Mild AKI          Likely 2nd to infection and poor oral intake          Baseline creatinine 1.0-1.1, now 1.49          Given 1 L IVF bolus in ER, will hold off on additional fluids with goal to keep COVID-19 positive patient is on the dry side          Daily basic panel to assess renal function and determine need for additional IV fluids  Hypophosphatemia          Given sodium phosphate 40 millimoles in ER          Recheck phosphorus in a.m.  Frequent PACs on telemetry          Daily monitoring of electrolytes including magnesium, replace p.r.n.  Generalized weakness          Likely 2nd to COVID-19 infection          PT/OT evaluations  Remote ischemic stroke without residual deficits Dyslipidemia          Continue home aspirin, atorvastatin  GERD          Continue home pantoprazole, especially while on steroids  Depressive disorder Generalized anxiety disorder          Continue home Lexapro and BuSpar  Diet:  General VTE ppx: Padua score is 6, will start subcutaneous Lovenox 40 mg daily Code status:  Full code.  Did discuss and confirm with patient.  Disposition: admitted as inpatient for acute respiratory insufficiency 2nd to COVID-19. Anticipated LOS > 2 midnights. HISTORY OF PRESENT ILLNESS Patient is a 77 y.o. male with medical history significant for dyslipidemia, remote ischemic stroke with no residual deficits, GERD, osteoporosis, generalized anxiety disorder.  Presents to ER for severe weakness for past few days.   Reports he was feeling at baseline health until about 5 days ago, developed progressive worsening of weakness, felt so weak that he was unable to walk on his own today and was unable to get out of a chair on his own.  Denies fall, head injury.  Says weakness is generalized, not one-sided.  No numbness or tingling in extremities.  No vision or speech changes noted.  He reports cough intermittently productive of clear phlegm, sore throat, mild dyspnea with exertion, loose stools.  Having chills but does not know about fever.  No chest pain or pressure.  No pain or swelling in his legs.  Denies sick contacts, his wife with whom he lives is not ill.  Notes he received initial COVID vaccine x2 and 1st booster in 10/2021.  Denies lung issues, cardiac issues.  Never smoker.  Takes aspirin 325 mg daily, no other blood thinners.  No history of blood clots.   In ER, afebrile at 101.5° F, mildly tachycardic.  Low normal blood pressures (patient states this is baseline for him).  Desatted to 89% on room air, 2 L nasal cannula applied.  EKG image independently reviewed showing a sinus tachycardia, frequent PACs, no acute ST changes when compared to prior EKG from 08/2021. Lab significant for mild AKI with creatinine 1.49, baseline 1.0-1.1.  WBC 12.76.  LA x2 normal.  ProBNP normal.  Found to be COVID-19 positive.  CXR image independently reviewed with no clear acute process noted though does have coarsened lung markings in right lower lobe, ?developing infiltrate.  Will admit to medicine for further management. REVIEW OF SYSTEMS Review of Systems  Constitutional: Positive for activity change, appetite change, chills and fatigue. Negative for diaphoresis and fever.  HENT: Positive for rhinorrhea and sore throat. Negative for congestion, sinus pressure, sneezing and trouble swallowing.   Eyes: Negative for visual disturbance.  Respiratory: Positive for cough and shortness of breath.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Positive for diarrhea. Negative for abdominal distention, abdominal pain, blood in stool, constipation, nausea and vomiting.  Endocrine: Negative for polyuria.  Genitourinary: Negative for difficulty urinating, dysuria, frequency, hematuria and urgency.  Musculoskeletal: Positive for back pain (Chronic low back pain) and myalgias. Negative for neck pain.  Skin: Negative for pallor and rash.  Allergic/Immunologic: Negative for immunocompromised state.  Neurological: Positive for weakness. Negative for dizziness, speech difficulty, light-headedness, numbness and headaches.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative for confusion and sleep disturbance. The patient is not nervous/anxious.   OBJECTIVE BP 94/62  | Pulse 100  | Temp (!) 101.5 °F (38.6 °C) (Oral)  | Resp 27  | Ht 1.626 m (5' 4")  | Wt 85.2 kg (187 lb 13.3 oz)  | SpO2 92%  | BMI 32.24 kg/m²  Physical ExamVitals and nursing note reviewed.  Constitutional:     General: He is not in acute distress.    Appearance: Normal appearance. He is not ill-appearing, toxic-appearing or diaphoretic.  HENT:    Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:    General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.     Comments: On 2 L supplemental oxygen, O2 saturations in mid 90s, no accessory muscle use or increased work of breathing noted Chest:    Chest wall: No tenderness.  Abdominal:    General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:       General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion. No tenderness.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:   General: Skin is warm and dry.     Coloration: Skin is not pale.     Findings: No erythema.  Neurological:    General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:       Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content Thought content normal.        Judgment: Judgment normal