Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Skin lesion, Skin ulcer, Skin warm, Staphylococcus test negative, Systemic inflammatory response syndrome
Clinical narrative: Hospitalized (1.13.22 - 1.16.22); COVID-19 positive (1.13.22); Fully vaccinated -moderna x2 D/c summary:  Discharge Summary , PA-C (Physician Assistant-Certified) ? ? Hospitalist Cosigned by:  DO at 1/16/2022  1:19 PM        BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider at Discharge: NP Admission Date: 1/13/2022 Discharge Date: 1/16/2022 Active Issues Requiring Follow-up Sepsis (HCC) Assessment & Plan Resolved   Acute respiratory failure (HCC) Assessment & Plan Resolved   Schizophrenia (HCC) Assessment & Plan Continue home meds 100mg Seroquel po daily at noon 800mg Seroquel po nightly 300mg Lamotrigine po nightly   Hypertension Assessment & Plan Continue home meds 20mg Furosemide po each morning   Diabetes mellitus (HCC) Assessment & Plan Lab Results Component Value Date   HGBA1C 5.6 01/06/2022     Resume home diabetic regimen at discharge   Cellulitis of right lower extremity Assessment & Plan Hx of nonhealing wound on R great toe, erythema up to right knee.   Appreciate Podiatry input- No  surgical intervention required MRSA screen with negative today.  Patient with previous history of MRSA infection Will discharge patient home to complete a 10 day antibiotic course on Augmentin 875/125       * COVID-19 Assessment & Plan Date of positive COVID-19 test: 1/14/2022 CXR: Cardiomegaly with pulmonary congestion and bilateral patchy airspace disease. No pleural effusions are present. No pneumothorax is present.    Currently on room air No further medication intervention necessary other than over-the-counter medications as needed for symptoms DISCHARGE DISPOSITION: Home without services DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Cellulitis of right lower extremity  Hypervolemia, unspecified hypervolemia type COVID-19 virus infection  COVID-19    HOSPITAL COURSE: 67-year-old male patient presented to the emergency department with lower extremity erythema and edema and significant tenderness extending just below his right knee.  Patient has chronic wound on the plantar aspect of the right foot.  In addition patient had persistent cough and shortness of breath with increased exertional dyspnea.  In the emergency department patient was noted to be positive for COVID.  Patient is schizophrenic and lives in adult care home.   Patient admitted with the following diagnoses:  Sepsis secondary to cellulitis, cellulitis of right lower extremity, schizophrenia, type 2 diabetes mellitus, acute respiratory failure secondary to positive COVID-19 with exertional dyspnea.  Currently on oxygen 3 L.    Treated with IV Unasyn.  Appropriate IV hydration.  Patient started on remdesivir and Decadron for COVID.  Continued home schizophrenia medications.  Placed on very low corrective short-acting insulin.  With appropriate therapy patient was able to be weaned back to room air while maintaining saturations in the high 90s at time of discharge.  Patient's leg was noted to have significant improvement of erythema and warmth to palpation with antibiotic therapy.  Leukocytosis also had resolved prior to discharge.  Podiatry consulted on the patient and did not recommend any surgical debridement of noted chronic ulcerations.  Recommend patient continue to follow with Podiatry as an outpatient.  Patient will be discharged back to facility with ongoing antibiotic therapy to complete a 10 day antibiotic course.     CONSULTS / RECOMMENDATION: Podiatry- follow-up for continued monitoring of chronic ulceration recommended   BP 104/74  | Pulse 88  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.829 m  | Wt 123.7 kg  | SpO2 97%  | BMI 36.99 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: He is well-developed. He is obese.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Musculoskeletal:     Cervical back: Normal range of motion and neck supple.     Comments: Continued erythema and edema of the right lower extremity noted, although improving throughout admission; minimal warmth to palpation  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.   H&P: Attestation signed by  MD at 1/14/2022  9:43 PM I have personally interviewed and examined the patient on 1/14/2022. Management was discussed with care management team.  I agree with the documented findings and plan of care in his/her note.   67-year-old male patient presented to the emergency department with lower extremity erythema and edema and significant tenderness extending just below his right knee.  Patient has chronic wound on the plantar aspect of the right foot.  In addition patient had persistent cough and shortness of breath with increased exertional dyspnea.  In the emergency department patient was noted to be positive for COVID.  Patient is schizophrenic and lives in adult foster care home.       Brief exam:     Vitals:   01/14/22 1932 BP: 97/50 Pulse: 109 Resp: 26 Temp: 36.8 °C Weight:   Height:     Heart-regular rate rhythm Lungs-clear to auscultation bilaterally Abdomen-soft, nontender, nondistended Right lower extremity-well-defined area of erythema extending to just below knee is well demarcated.     Assessment/plan:  Sepsis secondary to cellulitis, cellulitis of right lower extremity, schizophrenia, type 2 diabetes mellitus, acute respiratory failure secondary to positive COVID-19 with exertional dyspnea.  Currently on 3 L.    Please see orders at this time.  Placed on IV Unasyn at this time.  Appropriate IV hydration.  Patient started on remdesivir and Decadron for COVID.  Continue home schizophrenia medications.  Placed on very low corrective short-acting insulin.    Expand All Collapse All     Hide copied text  Hover for details    CHIEF COMPLAINT: COVID-19   Assessment/Plan     ASSESSMENT/PLAN: Sepsis (HCC) Assessment & Plan Sepsis secondary to cellulitis, likely worsened with concurrent covid infection.   -[3]/4 SIRS (leukocytosis, tachycardia, tachypnea) with lactate greater than 2 Lactic acid 2.3 -- > 2.5 -- > 1.8   IV fluid bolus held in the emergency department given COVID infection, and signs of pulmonary edema on chest x-ray, as well as elevated BNP Appreciate assessment and plan as noted under cellulitis and COVID-19.   Acute respiratory failure (HCC) Assessment & Plan Likely secondary to COVID, however question potential of acute heart failure given elevated BNP and peripheral pitting edema.   Oxygen via NC, titrate to maintain oxygen saturations > 88-92% Appreciate assessment and plan as noted above   * COVID-19 Assessment & Plan Date of positive COVID-19 test: 1/14/2022 CXR: Cardiomegaly with pulmonary congestion and bilateral patchy airspace disease. No pleural effusions are present. No pneumothorax is present.    Current oxygen requirement: SpO2: 95 % O2 Flow Rate (l/min): 3 l/min   CRP: Pending D-dimer: Pending Ferritin: Pending   Self Prone Albuterol INH 2 puffs q 6 hours Dexamethasone - 6 mg po/IV day 1/10 Remdesivir - 200 mg IV day 1, followed by 100 mg day 2-5 DVT prophylaxis: Lovenox Daily CBC w/diff, CMP, CRP, D-Dimer   Schizophrenia (HCC) Assessment & Plan Continue home meds 100mg Seroquel po daily at noon 800mg Seroquel po nightly 300mg Lamotrigine po nightly   Diabetes mellitus (HCC) Assessment & Plan  Lab Results Component Value Date   HGBA1C 5.6 01/06/2022     Hold home oral/injectable agents Very Low meal time and correction factor insulin scale Consistent carbohydrate diet Blood glucose checks per protocol   Cellulitis of right lower extremity Assessment & Plan Hx of nonhealing wound on R great toe, erythema up to right knee. BNP 5188 - BNP was 2141 1/6/2022.   Antibiotic: IV Vanc to be dosed by pharmacy and IV 3mg Unasyn q6 Echocardiogram pending secondary to pulmonary congestion, and lower extremity edema Right lower extremity ultrasound in a.m Blood cultures pending MRSA screen pending Wound cultures pending  Wound consult Podiatry consult CBC, BMP in am   Hypertension Assessment & Plan Continue home meds 20mg Furosemide po each morning HISTORY OF PRESENT ILLNESS: Patient is a 67 y.o. male with a past medical history of schizophrenia, hypertension and diabetes who presents today with leg swelling.  I did go down to the emergency department to evaluate this patient.  Patient is a poor historian as he has little insight into his illness.  He is able to answer some yes or no questions, but mostly his speech is tangential.  Majority report is from emergency department.  Patient was brought to the emergency department from his assisted living facility due to concerns of right lower extremity pain and swelling.  Pt a chronic nonhealing wound on his right great toe.  Since then redness has been spreading up to the knee.  He has not had any trouble walking, although he does typically utilize a walker.  Patient has also had 1 week of cough and shortness of breath.  Per report, patient is at his mental baseline.  Patient denies feelings of fevers or chills.  He does agree that he has been coughing.   In the emergency department patient was afebrile.  He was tachycardic, and tachypneic.  Oxygen supplementation was required initially at 2 L and then 3 L by time of admission.  Patient did meet SIRS criteria however typical fluid bolus was held due to concerns of elevated BNP, signs of pulmonary edema on imaging, and positive COVID test to avoid further fluid overloading patient.  Pertinent lab findings include a leukocytosis of 19.14.  BNP is found to be elevated at 5188, of note it was noted to be 2141 January 6, 2022. Troponins were found to be indeterminate at 30 and then 29 at recheck.  Lactic acid was initially elevated at 2.3, 2.5 at recheck and then 1.7 at recheck.  COVID test did return positive.  Peripheral blood cultures were taken.  EKG was shown to be in junctional rhythm.  Urinalysis not remarkable.  Chest x-ray showed cardiomegaly with pulmonary congestion and bilateral patchy airspace disease.  No pleural effusions are present no pneumothorax is present.  Given 40 mg of Lasix, 2 g of Rocephin, Tylenol and initiated on IV vancomycin to be dosed by pharmacy.  Due to concerns of acute respiratory failure secondary to COVID, as well as right lower extremity cellulitis, patient was admitted to hospitalist service.  Patient will be boarded in the emergency department overnight due to bed availability.     Patient Active Problem List Diagnosis ? COVID-19 ? Cellulitis of right lower extremity ? Diabetes mellitus (HCC) ? Hypertension ? Schizophrenia (HCC) ? Acute respiratory failure (HCC) ? Sepsis (HCC)  OBJECTIVE: BP 106/77  | Pulse 113  | Temp 97.9 °F (36.6 °C) (Oral)  | Resp 29  | Ht 1.829 m (6')  | Wt 123.7 kg (272 lb 11.3 oz)  | SpO2 96%  | BMI 36.99 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is obese. He is ill-appearing. He is not toxic-appearing or diaphoretic.     Comments: 3L NC in place  HENT:     Head: Normocephalic.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. Tachypnea present. No respiratory distress.     Breath sounds: No stridor. Decreased breath sounds present. No wheezing, rhonchi or rales.     Comments: Intermittant cough Chest:     Chest wall: No tenderness.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: Swelling present. No tenderness or deformity. Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity or tenderness.     Right lower leg: Edema (+2 pitting edema, erythema up to knee, pulses intact, sensation intact, no tenderness) present.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced or pale.     Findings: Erythema and lesion (2cm wound on right great toe, no purulence, no fluctuance, not tender) present.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. He is confused.     GCS: GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.     Cranial Nerves: No facial asymmetry.     Sensory: Sensation is intact.  Psychiatric:        Mood and Affect: Mood normal.        Speech: Speech is tangential.        Behavior: Behavior is cooperative.        Thought Content: Thought content normal.        Judgment: Judgment normal.