Age: 75.0
Sex: F
Vaccine: COVID19
Symptoms: Toxic encephalopathy, Tricuspid valve incompetence, Ultrasound Doppler abnormal, Urinary retention, Urinary tract infection
Clinical narrative: Vaccinated for COVID, admitted with COVID Admit 8/18 Discharge 9/3 to home with home health covid + 8/19/2021  Hospitalization Admit Date/Time: 8/18/2021  5:20 PM Discharge Date: 9/3/2021 Referring provider name and address:  No referring provider defined for this encounter.  75 yo F who is a poor historian but has been having dysuria, n/v and was hypoxic to 85% in triage. States that she was recently discharged from hospital w/ concern for urinary retention/UTI; has a hx of previous stroke and was sent to rehab. At rehab, states that she has had poor oral intake and has been feeling nauseous with intermittent emesis. Family in the room has been concerned that she was more confused recently. Does state that she has been having dysuria, of note was supposed to note be cathed 2/2 hx of frequent UTIs and was supposed to follow up with urology. Pt was having retention and was cathed multiple times/day.    Chief Concern, Brief History of Present Illness, and Hospital Course 75 y.o. female with a PMH of GERD, anxiety, depression, obesity, HTN, DMII, CVA with residual right sided weakness, breast cancer s/p mastectomy, and thyroid nodules s/p thyroidectomy who was admitted to hospital 7/24 to 8/6 for presented to ED from rehab on 8/19 with concerns for encephalopathy, hypoxia, dysuria and urinary retention. Found to be COVID positive on admission. Finished steroid and remdesivir course and now doing well in room air. PT/OT recommeneded acute rehab but denied by insurance. Hence, being discharged to SNF today.     Assessment and Plan on Discharge Day   Acute Hypoxic Respiratory Failure likely 2/2 COVID-19 PNA Chronic B/L Pleural Effusions (R>L) 2/2 HFmREF and mild/moderate MR -Hypoxic on presentation and requiring NC, now weaned off and satting well in room air since last few days -TTE 08/23 with EF of 40-50% with mild to moderate MR and signs of increased LVEDP, mild TR with ePASP of 35-50 mm Hg -COVID+ on 8/19.  -S/p Dexamethasone (08/19 - 08/28) and Remdesivir (8/19-8/23) -Pro-BNP on 8/23-03764>>3609 on 8/18 but no signs of volume overload clinically -XR chest 8/18 with B/L effusions (R>L) and B/L airspace opacities on L base and mid/lower right lung, rpt XR chest 9/1 AM with improved aeration of R effusion and decreased R sided effusion -No need for isolation on discharge given clinical symptomatic improvement and no fever for a while and >10 days since tested positive    AKI on CKD Stage IIIb/IV 2/2 COVID-19 ATN vs Obstructive AKI in the setting of preexisting diabetic nephropathy  (resolved) Urinary Retention POA s/p Foley's insertion UTI -Cr on presentation-1.53 (close to baseline of 1.5-1.7), peaked to 2.14 on 8/24 and now improved almost back to baseline to 1.60 on 9/3 -UA with pyuria/hematuria/proteinuria. Urine protein to creatinine ratio 5.0 suggestive of nephrotic range proteinuria (3.9 1 month ago) -CT abdomen (08/23) without evidence of hydronephrosis or obstruction. -Presented with urinary retention, failed voiding trial x3 this admission (Last on 9/2) -Urine Cx growing Klebsiella pneumoniae, given urinary retention requiring Foley's, will continue Cefdinir for 7 days course until 9/6 on discharge -Continue bowel regimen, encourage ambulation -Flomax stopped on 8/31 as there is no evidence of clinical benefit with flomax in urinary retention in females  -Sees urology as OP and reportedly had prior issues with urination as per sister, will try voiding trial again today, otherwise will plan to discharge with Foley's with OP urology follow up (has appointment scheduled on 9/8) -Monitor Cr as outpatient, repeat protein-creatinine ratio in 1 month -Follow up with nephrology as outpatient, referral provided   Acute metabolic encephalopathy (resolved) Oropharyngeal Dysphagia Hx of CVA with residual right sided weakness -Mental status back to baseline -On mech soft diet as per SLP -Continue ASA, statin and thiamine -Delirium precautions    Leukopenia and thrombocytopenia (resolved) Lymphopenia 2/2 due to COVID Normocytic Anemia 2/2 Anemia of CKD -WBCs-3.29 on 8/18, decreased to 1.81 on 8/21, improved to 5.61 on 9/1 -Lymphocyte 0.68 on 8/18, decreased to 0.25 on 8/23 and improved to 1.34 on 9/1 -Plt 155 on 8/18, decreased to 128 on 8/25 and improved to 159 on 9/1 -Hb 9.3 on admission, stable at 8.9 on 9/1 (prior iron studies on 7/26 suggestive of AOCD) -B12/folate normal -Blood smear with Leukopenia including neutropenia with normal white blood cells morphology and moderate normocytic anemia with anisocytosis and rare schistocytes, Normal platelets     Hypomagnesemia (resolved) -Mg: 2.0 on 8/26<<1.4 on 8/20   Physical Debility with Chronic T12 Compression Fracture and CVA with Right Sided Weakness  -Tylenol and lidocaine patch PRN -PT/OT-recs acute rehab, however denied by insurance despite peer to peer review, hence, being discharged to home with home health today   Right Lower Extremity Edema  -Pt reports this is chronic but a poor historian -Venous duplex -ve for DVT   Type 2 DM -Last A1c 8.5% on 7/25 -Maneged with basal/bolus insulin regimen while inpatient -Resume home Tradjenta and start lantus 5 U daily on discharge     Hypertension  -Continue same doses of home Nifedipine and Isosorbide and increased dose of coreg 25 BID on discharge   Depression Anxiety  -Continue home Effexor