Age: 82.0
Sex: M
Vaccine: COVID19
Symptoms: Cough, Dehydration, Dysphagia, Enteral nutrition, Fungal test positive
Clinical narrative: Clinical Summary Patient is a 83 y.o. male with a history of Crohn's Disease, HTN who presented to the HCF 7/11/22 with acute on chronic back pain without trauma. CT L-spine with mild to moderate DDD without significant spinal canal stenosis, mild bilateral neural foraminal narrowing. Transferred to HCF Observation 7/12/2022 for PT/OT evaluation. COVID+ with ongoing cough for 3 weeks PTA. Hospitalization was complicated by new onset fevers and dysphagia. PEG placed 7/22/22. Prolonged stay for SNF placement.   1. Acute on Chronic Back Pain: with increased difficulty ambulating, ambulates with cane at baseline. No trauma/injury. CT L-spine with mild to moderate DDD without significant spinal canal stenosis, mild bilateral neural foraminal narrowing. Pain control. PT/OT followed. 2. COVID-19 infection: vaccinated x2, boosted x1. COVID+ 7/12/22 with dry cough x3 weeks PTA. Acute onset generalized weakness and then new fevers 7/15/22. No significant hypoxia noted. CRP >200, ferritin 900s. No indication for steroids yet but will continue to monitor. Not a candidate for remdesivir or MAB per ID. ID followed given ongoing symptoms but new onset fevers, Covid CT value consistent with infectious levels and IgG positive. ID stated not a mab infusion candidate.  3. Fever: Noted multiple times 7/15/22. ?Persistent Covid infection but unusual that it would just be occurring now after having cough for 3 weeks. Possible superimposed bacterial PNA that might not be apparent by CXR due to recent dehydration. Full infectious work up with CXR, urine antigens, blood cultures, sputum culture, repeat UA, lactate, MRSA probe and procal mostly unremarkable. CRP significantly elevated at 204 with normal ESRD. Respiratory PCR panel +Covid but nothing else. Immunocompromised which complicates picture. Azathioprine held. Empiric Rocephin/Azithro added 7/15/22 with no recurrence of fever thereafter. Completed 7 day course of rocephin 7/21/22. ID followed. Resume imuran as outpatient week of 8/1/22.  4. Generalized weakness: Likely due to Covid-19 and possibly other superimposed infection being work up as above. PT/OT followed 5. Dysphagia: Ongoing cough, worse with any intake. Failed MBS 7/14/22, SLP recommended NPO and tube feeds started through NG 7/16/22. Failed repeat MBS 7/21/22 and SLP recommended NPO except ice chips. Palliative care followed. PEG placed 7/22/22.  6. Acute Metabolic Encephalopathy: with progressive confusion since hospitalization. No new focal neuro deficits. Oriented x3 7/19/22.  7. Vasovagal Syncope: Witnessed, on bedside commode while having BM 7/13/22. BP 68/30. Improved after IVF. No recurrence.  8. Crohn's Disease: Continued home Imuran initially but then discontinued in the setting of active fevers/infection. Defer resuming Humira to primary GI as outpatient.  9. HTN: Adjusted home norvasc, ARB, initiated Coreg.  10. Abnormal CT: noted L spine with multilevel DDD, L3-L4, L4-L5 without significant spinal canal stenosis. Noted bilateral non obstructive nephrolithiasis.  11. Abnormal Sputum Culture: sputum culture showed moderate yeast 7/16/22. Abnormal sputum culture is clinically undetermined