Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Productive cough, Thrombocytopenia, Type 2 diabetes mellitus
Clinical narrative: ID: Patient    Date of Admission:  11/11/2023    Date of Discharge:  11/13/2023    Primary Care Physician:  No primary care provider on file.   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/11/2023 12:21 PM BLOOD CULTURE 2 Preliminary BLOOD   11/11/2023 11:39 AM BLOOD CULTURE Preliminary BLOOD       Issues to be Addressed in Follow-up: None    Reason for Hospital Admission (Admitting Diagnosis):  Hypoxia, COVID, AKI    HPI on admission:  Patient is a 64 Y male with past medical history significant for COVID about one year ago requiring ICU care (31 days), hx of DM 2, neuropathy, hx of substance abuse disorder (cocaine in the past), and hx of DM foot ulcer as well as non-proliferative retinopathy who presents with complaint of weakness, dizziness, chest tightness and cough.   Patient states that he has had a productive cough for about a week, associated with chest discomfort especially when he coughs and turns, and then last night he noted weakness that made him fall and he could not get off the commode. No LOC or head trauma. His cough is productive of white phlegm. He has not had any fever at home but did note that his bed was soaked with perspiration one night. Last night he felt as bad as he felt when he had his last bought of covid where he was hospitalized in the hospital for 31 days. Here in the ED, he was noted to be hypoxic to 87% on RA and was placed on O2 via NC. He is noted to have LA of 2.3 that has resolved with 1 L NS.     Cough is productive of white phlegm. States that he has chest tightness, only present when he turns in bed and coughs. + dizziness, weakness, myalgias/arthralgias. No melena, hematochezia, hematemesis. Oral intake is good. States has urinary frequency due to an enlarged prostate and this has not changed. No shortness of breath. Lives alone, thinks he may have caught covid from a co-worker.     Hospital Course and Significant Findings: This 64 Y diabetic male comes in with acute weakness, chest tightness, cough.  Found to have covid.  Significant history of 30d hospitalization a year ago for covid.  Sat 87% on admit.  Put on dexamethasone, remdesivir, admitted.  Promptly improved inhouse, weakness, hypoxia resolved.  On 11/13, d/c'd home on nothing.  Gave isolation instructions.  Transient hyperglycemia inhouse due to dexamethasone.    Studies:  CXR     No acute disease.   Complications:  none   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)   ? HYPOXIA   ? NONTRAUMATIC ACUTE KIDNEY INJURY   ? DM 2 W POLYNEUROPATHY     Resolved Hospital Problems No resolved problems to display.   Primary Procedures:   None    Secondary Procedures: None   Consults:  None     Condition on Discharge:  stable   Code Status at Time of Discharge: Full Code   Discharge Disposition:  Home   Discharge Medications: See AVS for discharge meds Pertinent medication changes:   ? None              MD      Note Details  Author  (M.D.) File Time 11/13/2023 10:27 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine  Admit Date 11/11/2023  ED to Hosp-Admission (Discharged) on 11/11/2023  ED to Hosp-Admission (Discharged) on 11/11/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   DM 2 W POLYNEUROPATHY  COVID-19 DISEASE  THROMBOCYTOPENIA, UNSPECIFIED (UNKNOWN ETIOLOGY)  HYPOXIA  NONTRAUMATIC ACUTE KIDNEY INJURY Care Timeline  11/11   Admitted from ED (Observation) 1657 11/13   Discharged 1222  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/13/2023) Medication List at Discharge   acetaminophen 650 mg Oral EVERY 6 HOURS AS NEEDED, . Do not exceed 10 tablets in 24 hours  albuterol 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED  aspirin 81 mg 1 tablet Oral DAILY  docusate sodium 100 mg Take 1 to 2 capsules by mouth at bedtime as needed for constipation  hydrocortisone 2.5 % Topical 2 TIMES A DAY  insulin glargine,hum.rec.anlog Inject 25 Units subcutaneously daily at bedtime  insulin glargine-yfgn 25 Units Subcutaneous EVERY BEDTIME  insulin lispro 10 Units Subcutaneous 3 TIMES A DAY  loratadine 10 mg Oral DAILY AS NEEDED  losartan potassium 50 mg Oral DAILY