Age: 61.0
Sex: M
Vaccine: COVID19
Symptoms: Magnetic resonance imaging spinal abnormal, Mastoiditis, Mental status changes, Monocyte count increased, Multiple organ dysfunction syndrome
Clinical narrative: ED to Hosp-Admission Discharged  4/3/2021 - 4/10/2021 (7 days) Hospital  MD Last attending ? Treatment team Severe sepsis with acute organ dysfunction Principal problem Discharge Summary MD (Physician) ? ? Internal Medicine         HOSPITAL INPATIENT DISCHARGE SUMMARY HOSPITALIST GROUP .   Date: 4/10/2021 Admission Date: 4/3/2021 Length of stay: 6 Days PCP: MD Discharging provider: MD    Admission diagnosis:     Primary Admission Diagnosis    Hospital Problems          POA   * (Principal) Severe sepsis with acute organ dysfunction Yes       Left hip pain Yes       Primary osteoarthritis of left hip Yes       Intractable vomiting with nausea Yes       Acute metabolic encephalopathy Yes       COVID-19 virus infection Yes       Gastrointestinal hemorrhage with hematemesis No       Urinary tract infection associated with indwelling urethral catheter Yes                HPI: Admitted with severe left hip pain and altered mental status. patient with history of stroke Was also found to have Covid positive at the time of admission     Hospital Course:    Following issues were addressed during this hospitalization   Acute encephalopathy: At the time of admission Most likely secondary to gabapentin Held medication during this hospitalization and also stopped at the time of the discharge. Patient was started on this medication recently due to his left hip pain.   COVID-19 infection D-dimer was elevated at the time of presentation.  CT chest ruled out pulmonary embolism.  Ultrasound did not reveal any DVT. Patient did not qualify for any convalescent plasma remdesivir during this hospitalization as he is saturating well on room air.   Possible catheter associated urinary tract infection Patient with chronic indwelling Foley catheter. Urine culture grew Staphylococcus hemolyticus and Enterococcus faecalis faecalis. Patient was started on ampicillin during this hospitalization he completed the 5-day course.   Sepsis ruled out at the time of admission   Acute kidney injury present at the time of admission Suspect underlying chronic kidney disease Patient needs to follow-up with the PCP for the follow-up on the creatinine in 1 week.   Left hip pain Patient underwent extensive work-up during this hospitalization.  MRI of the left hip showed high-grade tear of the iliopsoas tendon.  Patient was seen by orthopedics recommending continued therapy and pain management.   Acute GI bleed, presented as coffee-ground emesis Acute on chronic anemia Iron deficiency anemia Underwent extensive work-up during this hospitalization.  CT angiogram of abdomen pelvis revealed suspected bleeding in the stomach.  Patient underwent EGD which showed severe esophagitis most likely cause of the bleed. Gastroenterology recommending continuing pantoprazole twice daily. Patient hemoglobin remained stable during this hospitalization. Biopsy did not reveal any H. pylori infection.   Patient was seen by PT OT during this hospitalization who recommended acute inpatient rehab.  But patient and family decided to take the patient home patient was discharged home in stable condition with home health.