Age: 98.0
Sex: M
Vaccine: COVID19
Symptoms: Cachexia, Candida infection, Capillary nail refill test, Cardiac failure congestive, Cardiac murmur
Clinical narrative: Hospitalized (1.14.22 - 1.18.22); COVID-19 positive (1.14.22); Fully vaccinated  - J&J x1 D/c summary:  Discharge Summary   BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 1/14/2022 Discharge Date: 1/18/2022   Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 01/14/2022 Yes ? Elevated brain natriuretic peptide (BNP) level 01/15/2022 Clinically Undetermined ? Paroxysmal atrial fibrillation  01/15/2022 No ? Pressure injury of lower back, stage 2  01/15/2022 Yes ? Protein calorie malnutrition  01/15/2022 Yes ? Right corneal abrasion 01/14/2022 Yes ? Candida esophagitis  07/22/2015 Yes ? HTN (hypertension)   Yes ? Controlled type 2 diabetes mellitus with complication, without long-term current use of insulin    Yes ? GERD (gastroesophageal reflux disease)   Yes ? Prostate Cancer  05/29/2008 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Delirium 01/14/2022 01/18/2022 Yes ? Dehydration 01/14/2022 01/18/2022 Yes DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Delirium [R41.0] Weakness [R53.1] Corneal ulcer, right [H16.001] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 99-year-old male who presented for evaluation due to confusion. The patient has 24/7 private duty caregivers at baseline. He had been eating less and having increased weakness for about 2 weeks prior to admission. In the past he has had trouble with confusion whenever he has an infection. In the ER the patient was found to be COVID positive. He was hypoxic requiring 1L NC. He had no leukocytosis, a negative procal. CXR showed mild cardiomegaly and vascular congestion suggestive of CHF. He had a head CT which was negative for any acute changes. The patient appeared dry on exam and was started on IVF as well as dexamethasone due to COVID. He was noted to have a right corneal abrasion and the ER provider spoke with Dr. of ophthalmology. Dr. recommended moxifloxacin eyedrops every hour and QID erythromycin ointment and outpatient follow up. He was admitted to the hospitalist team for further management. He was started on a course of dexamethasone and he was quickly weaned off of oxygen and his mental status improved. His IVF were stopped after a BNP obtained was significantly elevated at 27,554. Due to his elevated D-dimer and significant elevation in BNP a CTA thorax was obtained to r/o PE. There was no evidence of PE but there was evidence of atypical or developing COVID pneumonia. Due to his elevated BNP an echo was obtained which showed an EF of 50%. He was not started on diuretics as he had no respiratory distress and was on room air. He was evaluated by PT/OT who felt that he could return home with his 24 hour care however several of his private duty caregivers were also sick with COVID and therefore he was unable to return home. Care management arranged for placement at another facility. At discharge he was continued on dexamethasone to complete a 10 day course of steroids, he was also continued on the eye drops and ointment for his corneal ulcer. The patient will need outpatient follow up with his PCP as well as with ophthalmology regarding his right corneal ulcer.     CONSULTS / RECOMMENDATION: PT/OT Care management   INPATIENT PROCEDURES: None BP 175/64  | Pulse 64  | Temp 36.2 °C (Oral)  | Resp 16  | Ht 1.702 m  | Wt 46.5 kg  | SpO2 98%  | BMI 16.06 kg/m²    Physical Exam Constitutional:      Appearance: He is cachectic.  HENT:     Head: Normocephalic and atraumatic.  Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregularly irregular.     Pulses: Normal pulses.     Heart sounds: Murmur heard.   Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Abdomen is flat.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:General: Skin is warm and dry.     Comments: Dry flaky skin  Neurological: Mental Status: He is alert. Mental status is at baseline.  Psychiatric:    Mood and Affect: Mood normal   H&P: CHIEF COMPLAINT: COVID-19  ASSESSMENT / PLAN: Dehydration Assessment & Plan Gentle hydration. Watch closely for fluid overload  Delirium Assessment & Plan Mental status changes from baseline. Normally works every day and "is sharp as a tack" confused not taking meds and decreased oral intake.  Multifactorial: infection, hypoxia, dehydration, age   Right corneal abrasion Assessment & Plan History of reconstruction of right side of face and issues closing right eye at baseline and uses eye drops Concern that not using his drops recently with AMS ER spoke with opthalmology who recommended Moxifloxacin drops every hour (15 min prior to Erythromycin ointment) and Erythromycin ointment every 4 hours  Continue to monitor    Chronic migraine Assessment & Plan Continue home meds   Candida esophagitis  Assessment & Plan Nystatin swish and swallow    History of colon cancer Assessment & Plan S/p resection HTN (hypertension) Assessment & Plan Continue current meds. Monitor is slightly elevated.  Controlled type 2 diabetes mellitus with complication, without long-term current use of insulin  Assessment & Plan Assistant states did not know has diabetes. As is in history and giving steroids will monitor AC BS. If elevated may need mealtime coverage.  GERD (gastroesophageal reflux disease) Assessment & Plan Pt on very high dose PPI continue  Prostate Cancer  Assessment & Plan Continue current meds * COVID-19 Assessment & Plan Per assistant with pt here today started with illness Monday. Just went downhill. More confused. Not eating well. She is concerned he has UTI as he has had those in past.  Pt was found to have COVID today minimal symptoms except mild hypoxia and delirium.  Single vaccination with J and J.  HISTORY OF PRESENT ILLNESS: Patient is a 99 y.o. male who presents today with confusion Per "assistant" here with patient he normally is sharp as a tack and normally works daily. Monday (1/10/22) started going downhill. More confusion, not eating, not drinking, forgetting meds. Weaker. Family had her bring to ED. Concerned he has UTI as has had multiple in the past. She is concerned he is dehydrated.  Pt was found to be slightly hypoxic and positive for COVID and slightly dehydrated. We were consulted for admission. . Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for chills and fever.  HENT: Positive for hearing loss and ear pain. Negative for congestion and sore throat.  Eyes: Positive for eye discharge, itching and redness. Negative for visual disturbance.  Respiratory:  Negative for cough, wheezing, shortness of breath, chest tightness and sputum production.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for urinary incontinence and dysuria.  Musculoskeletal:  Negative for joint pain and muscle pain.  Neurological:  Positive for headaches, speech difficulty and weakness. Negative for dizziness, light-headedness, loss of consciousness and numbness/tingling.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Positive for itching. Negative for rash.  OBJECTIVE: BP (!) 181/106  | Pulse 85  | Temp 36.5 °C (Axillary)  | Resp 17  | SpO2 98%    Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: He is cachectic. He is ill-appearing.     Interventions: Nasal cannula in place.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: Decreased hearing noted.     Left Ear: Decreased hearing noted.     Nose: Rhinorrhea present. No nasal deformity.     Mouth/Throat:     Lips: Pink.     Mouth: Mucous membranes are dry.     Dentition: Normal dentition.     Pharynx: Posterior oropharyngeal erythema present.     Comments: Thrush  Eyes:     General: Lids are normal.     Extraocular Movements:     Right eye: Abnormal extraocular motion present.     Left eye: Normal extraocular motion.     Conjunctiva/sclera:     Right eye: Right conjunctiva is injected. Exudate present.     Comments: Right lid decreased movement. Large white corneal ulcer on right eye.   Neck:     Thyroid: No thyroid mass.     Vascular: No carotid bruit.     Trachea: Trachea normal.  Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregular.     Pulses: Decreased pulses.     Heart sounds: Murmur heard.   Systolic murmur is present with a grade of 3/6.    Pulmonary:     Effort: Accessory muscle usage present. No respiratory distress.     Breath sounds: Normal breath sounds. Decreased air movement present.  Chest:     Chest wall: No deformity or tenderness.  Abdominal:     General: Bowel sounds are decreased.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple. Decreased range of motion.     Thoracic back: Deformity (mild kyphosis. atrophy of paraspinal muscles. ) present.     Lumbar back: Normal.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is cool and dry.     Capillary Refill: Capillary refill takes more than 3 seconds.     Findings: Abrasion present  Comments: Dry, decreased tugor.   Neurological:     Mental Status: He is alert. He is disoriented.     Cranial Nerves: Facial asymmetry present.     Motor: Weakness present. No tremor.     Deep Tendon Reflexes:     Reflex Scores:      Patellar reflexes are 1+ on the right side and 1+ on the left side. Psychiatric:        Attention and Perception: Attention normal.        Mood and Affect: Mood normal.        Speech: Speech is slurred and tangential.        Behavior: Behavior is slowed. Behavior is cooperative.        Cognition and Memory: Memory is not impaired.