Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Dehydration, Dementia, Essential hypertension, Fluid intake reduced, Glycosylated haemoglobin normal
Clinical narrative: Hospitalized (5.24.22 - 5.26.22); COVID-19 positive (5.25.22);  fully vaccinated PLUS Booster- moderna x3 Discharge Summary  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: FNP Admission Date: 5/24/2022 Discharge Date: 5/25/2022   Active Hospital Problems   Diagnosis Date Noted POA ? Cystitis 09/21/2020 Unknown ? Generalized weakness 05/24/2022 Unknown ? PAF (paroxysmal atrial fibrillation)  03/09/2021 Yes ? Unspecified severe protein-calorie malnutrition  10/22/2020 Yes ? Type 2 diabetes mellitus with circulatory disorder, with long-term current use of insulin 02/03/2017 Yes ? Essential hypertension 02/03/2017 Yes ? Mixed hyperlipidemia 02/03/2017 Yes ? Primary hypothyroidism   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness [R53.1]  HOSPITAL COURSE: Per Admission H&P,"Patient is a 78 y.o. female who presents today with Arrives with history of diabetes, hypertension, hyperlipidemia, hypothyroidism, dementia, afib and a cva with increased confusion. Per her husband she has not been eating or drinking as much as usual and has increase weakness and confusion. He denies any falls or 1 sided weakness. He decided to call an ambulance and have her evaluated at the emergency department.    Upon arrival to ER her vitals were stable and she was afebile. She denies any complaints. Her blood work shows dehydration and her urine appeared infected. She was started on Macrobid and given 1 liter of NS.   Patient has underlying dementia likely worsened by dehydration and urinary tract infection.  Patient is a very poor historian.  Patient usually ambulates with walker and has prosthetic for her leg.  PT OT recommend skilled nursing facility.  Patient has an elevation in her BUN creatinine at 38 and 1.2 to compared to February.    Patient responded well to IV fluid hydration and antibiotics.  Her urine culture grew mixed flora.  However given her symptoms we will provide additional 3 days of coverage.  On the day of discharge patient improved significantly.  She was sitting up in the chair and was seen by writer eating breakfast and then lunch and then with husband at bedside.  Writer reviewed lab work imaging and treatment course with husband.  Patient has anemia and on review appears at baseline.  She reports no bleeding.  In 2020 there was a stool for occult blood that was positive.  It appears patient is on iron supplement.  Discussed with husband that she would need to follow-up with her primary care physician for further workup and treatment.  Also discussed risk and benefits of going to skilled facility versus going home.  Husband states that they live alone in their home.  Their children do not live by them.  Husband states that she was not eating or drinking and he could not help her and called EMS.  Writer discussed that skilled nursing facility will likely benefit her however that may expose her to other pathogens such as influenza or COVID.  Writer also discussed that going home with patient would be challenging as she is just regaining her strength.  Writer also expressed concern that if he was not able to move her or they fell they could sustain injury or fracture.  Husband agreed and was happy with going to skilled nursing facility.  Writer also discussed with husband to think about assisted living or independent living.  Writer encouraged husband to talk to their children about these options.  Questions and concerns addressed.  Both patient and husband were appreciative of assistance offered.  Writer did try to reach out to patient's daughter but could not reach her over the phone.  Active Issues Requiring Follow-up  1. Anemia 2. Dementia with decline 3. Living arrangement and discussion about independent living or assisted living   CONSULTS / RECOMMENDATION: IP CONSULT TO CARE MANAGEMENT IP CONSULT TO NUTRITION OBJECTIVE:   BP (!) 98/40  | Pulse 62  | Temp 36.1 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 60.6 kg  | SpO2 91%  | BMI 20.92 kg/m²    Physical Exam   Vitals and nursing note reviewed.  Constitutional:     Appearance: Normal appearance.  HENT:    Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:    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.  Abdominal:    General: Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:     General: No swelling.     Cervical back: Normal range of motion.     Comments: R BKA  Skin:   General: Skin is warm.  Neurological:    Mental Status: She is alert. Mental status is at baseline 5/24/22 H&P:  CHIEF COMPLAINT:    Generalized weakness ASSESSMENT/PLAN:  Principal Problem:   Generalized weakness Active Problems:   Type 2 diabetes mellitus with circulatory disorder, with long-term current use of insulin   Essential hypertension   Mixed hyperlipidemia   Primary hypothyroidism   PAF (paroxysmal atrial fibrillation)  Generalized weakness Assessment & Plan Patient sent to ER by husband by ems. She has become increasingly weak and confusion is getting worse. It is becoming more difficult for him to take care of her at home. She does have home nurse that comes for venous stasis would care. No falls reported or injury. Her husband is concerned that she has not been eating or drinking and could be dehydrated.She did receive a liter of NS in ER. Mag was 1.2. Creat was 1.22 and BUN elevated, this is increased from baseline.   Plan -PT/OT/SLP evaluation -Daily BMP -monitor routine vital signs PAF (paroxysmal atrial fibrillation)  Assessment & Plan Monitor vital signs. Continue daily xarelto PO.     Primary hypothyroidism Assessment & Plan Tsh 2.44 today. Stable. Continue home po Synthroid daily.   Mixed hyperlipidemia Assessment & Plan Continue home po daily atorvastatin. Stable  Essential hypertension Assessment & Plan Stable.  Continue home daily losartan orally.  Monitor routine vital signs.   Type 2 diabetes mellitus with circulatory disorder, with long-term current use of insulin Assessment & Plan Low dose basal insulin. Carb consistent diet.  Routine Accu checks.  Hemoglobin a1c   Lab Results Component Value Date   HGBA1C 8.3 (H) 01/24/2022 HISTORY OF PRESENT ILLNESS: Patient is a 78 y.o. female who presents today with Arrives with history of diabetes, hypertension, hyperlipidemia, hypothyroidism, dementia, afib and a cva with increased confusion. Per her husband she has not been eating or drinking as much as usual and has increase weakness and confusion. He denies any falls or 1 sided weakness. He decided to call an ambulance and have her evaluated at the emergency department.   Upon arrival to ER her vitals were stable and she was afebile. She denies any complaints. Her blood work shows dehydration and her urine appeared infected. She was started on Macrobid and given 1 liter of NS. Agreeable for admission for generalized weakness and PT /OT evaluation. .  OBJECTIVE: Review of Systems Constitutional:  Positive for appetite change. Negative for activity change, fatigue and fever.  HENT: Negative for congestion and sore throat.  Respiratory:  Negative for cough, wheezing, shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for difficulty urinating, urinary incontinence and dysuria.  Musculoskeletal:  Negative for joint swelling, muscle pain and gait problem.  Neurological:  Negative for headaches, dizziness, light-headedness and numbness/tingling.  Psychiatric/Behavioral:  Negative for anxiety, sleep disturbance and behavioral problems.  Skin:  Positive for wound.   No vitals were available at the time this note was created    Physical ExamVitals reviewed.  Constitutional:     General: She is awake. She is not in acute distress.    Appearance: She is not ill-appearing.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:    Effort: No tachypnea, accessory muscle usage or respiratory distress.     Breath sounds: Normal breath sounds and air entry.  Abdominal:    General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:    Right lower leg: No edema.     Left lower leg: No edema.       Legs:   Right Lower Extremity: Right leg is amputated below knee.  Skin:  General: Skin is warm and dry.     Coloration: Skin is not jaundiced.  Neurological:   Mental Status: She is alert. Mental status is at baseline. She is confused.     Cranial Nerves: No cranial nerve deficit or facial asymmetry.     Motor: No weakness or pronator drift.  Psychiatric:      Attention and Perception: Attention normal.        Mood and Affect: Mood normal.        Speech: Speech is delayed.        Behavior: Behavior is not agitated or aggressive. Behavior is cooperative.        Cognition and Memory: Cognition is impaired. Memory is impaired.