Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Hypoxia, Inguinal hernia, Insulin therapy, Lower urinary tract symptoms, Malaise
Clinical narrative: Hospitalized (12.9.21 - 12.14.21); COVID-19 positive (12.8.21); Fully vaccinated - moderna x2 D/c summary: Discharge Summary (NAME) MD (Physician) ? ? Hospitalist BRIEF OVERVIEW: Discharge Provider: (NAME) MD Primary Care Provider: (NAME) DO Admission Date: 12/9/2021 Discharge Date: Dec 14, 2021    Code Status: DNR    Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 12/10/2021 Yes   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Type 2 diabetes mellitus with stage 3b chronic kidney disease 06/10/2021 Unknown ? Type 2 diabetes mellitus with diabetic neuropathy 06/10/2021 Unknown ? Community acquired bacterial pneumonia 01/26/2021 Unknown ? Aortic valve sclerosis   Unknown ? BPH with obstruction/lower urinary tract symptoms   Unknown ? Bilateral inguinal hernia without obstruction or gangrene 01/10/2020 Unknown ? Umbilical hernia without obstruction and without gangrene 01/10/2020 Unknown ? OSA (obstructive sleep apnea)   Unknown ? Bladder stone   Unknown ? Pulmonary nodules   Unknown ? AAA (abdominal aortic aneurysm)   Unknown ? Renal cyst, acquired, right   Unknown ? Status post insertion of drug-eluting stent into right coronary artery, 08/16/2018 11/14/2019 Unknown ? CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min (HCC)   Unknown ? Diabetes mellitus, type II (HCC)   Unknown ? Neuropathy   Unknown ? Essential hypertension   Unknown ? Obesity (BMI 30.0-34.9) 11/14/2018 Unknown ? Coronary artery disease without angina pectoris   Unknown ? Mixed hyperlipidemia 07/09/2018 Unknown ? Chronic obstructive pulmonary disease, (COPD) 07/09/2018 Unknown ? History of tobacco use 07/09/2018 Unknown      Medication List   START taking these medications  amoxicillin-clavulanate 875-125 MG per tablet Commonly known as: AUGMENTIN Take 1 tablet by mouth 2 times daily for 5 days.   apixaban starter pack 5 MG Tbpk tablet Commonly known as: ELIQUIS Take as directed on starter pack - 2 tablets by mouth twice daily for 7 days, then 1 tablet by mouth twice daily   loperamide 2 MG capsule Commonly known as: IMODIUM Take 1 capsule by mouth 4 times daily as needed for Diarrhea.  Discharge Disposition:  home health care svc    Active Issues Requiring Follow-up:    COVID-19 pneumonia  Follow-up with primary care provider Patient was given steroids for 5 days while in the hospital but declined continued steroids outpatient for his COVID-19 infection.  He received 4 days of remdesivir.  He was weaned down to his home oxygen of 3 L.    Acute pulmonary emboli is complication of COVID-19 infection Follow-up with primary care provider Patient was on heparin drip initially and transitioned to Eliquis.   Groin cellulitis Follow-up with primary care provider or urology Patient has significant bilateral hernias that contribute to swelling in his scrotum.  Patient had signs concerning for cellulitis.  He was started on vancomycin and clindamycin along with Zosyn.  MRSA screen was negative and vancomycin and clindamycin were discontinued.  His antibiotics were deescalated to Augmentin at the time of discharge and he was prescribed 5 more days to complete a 10 day total course.   Pending Labs    Order Current Status   Peripheral Blood Culture Preliminary result   Peripheral Blood Culture Preliminary result     DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute pulmonary embolism as complication of COVID-19 infection COVID-19 Groin cellulitis   HOSPITAL COURSE: Patient is a 70-year-old man who presented to hospital with dyspnea and shortness of breath.  He had acute on chronic hypoxic respiratory failure and findings of pulmonary emboli on CT angiogram thorax.  He also was positive for COVID-19.  He was started on steroids and heparin drip.  He was later transitioned to Eliquis.  Echocardiogram was obtained that showed no right heart strength.  His oxygen was weaned down to his home level of 3 L. due to the steroids he did have significant hyperglycemia during his stay which was treated with insulin.  There is also concern for groin cellulitis.  His scrotum was very tender to touch and erythematous.  Imaging showed edema and his inguinal hernias.  He was initially started on clindamycin, vancomycin and Zosyn.  MRSA screen is negative and clindamycin/vancomycin were discontinued.  He received 5 days of antibiotics in the hospital.  He was transitioned to Augmentin for 5 more days to complete a 10 day total course outpatient per Infectious Disease recommendations.  At the time of discharge the patient said that he did not want to continue steroids any longer due to the complication of hyperglycemia.  He did not want to try to use insulin at home.  Patient was discharged home with a prescription of Eliquis and Augmentin.  He also had some diarrhea during his stay likely secondary to antibiotics and COVID-19 infection.  Imodium was prescribed.  Patient to follow-up with his primary care provider.    BP 126/56  | Pulse 54  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.727 m  | Wt 109.1 kg  | SpO2 93%  | BMI 36.57 kg/m²  FIO2 (%): 50 % Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not diaphoretic.  HENT:     Head: Normocephalic.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rales present. No wheezing.  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.  Genitourinary:    Comments: Scrotal swelling and erythema Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.    H&P: CHIEF COMPLAINT: Weakness   Subjective      HISTORY OF PRESENT ILLNESS: 70-year-old male who presents for weakness and dyspnea.   70-year-old male that presents after developing worsening hypoxia at home.  Patient is on 3 L nasal cannula at baseline and was required a non-rebreather via EMS to get his oxygen saturations up.  In the emergency department patient was transition to high-flow and a CT was obtained.  CT showed pulmonary embolism with evidence of right heart strain.  Per verbal communication from Dr.:  Dr. spoke with interventional radiologist (NAME) who did not feel that patient was a candidate for any intervention.  Patient was started on heparin drip in the emergency department.  Patient was also found to have a swollen red groin and was covered with Zosyn, vancomycin, and clindamycin.  A CT abdomen pelvis was obtained with no acute abnormality.  Hospitalist service was asked to admit patient for further management of their acute on chronic hypoxemic respiratory failure and groin cellulitis.   At the time of this providers exam patient is resting quietly in ED stretcher.  Patient states that he has felt sick 2-3 days.  Patient had covid test that was positive outpatient.  Patient has had fever, chills, increasing dyspnea (3L NC at baseline), diarrhea (non-bloody, non-tarry),    Patient states that he was vaccinated a couple of months ago.  Patient cannot remember if he had Pfizer or Moderna.  Patient can also not remember the exact month of his vaccinations.   Redness and swelling on scrotum.  Started a couple of days ago.  No other skin rashes.   Patient denies  chest pain, falls, syncope, abdominal pain, nausea, vomiting, constipation, dysuria, hematuria, increased urinary frequency, headaches, numbness, tingling, one-sided weakness, vision changes, homicidal thoughts or suicidal thoughts.   Emergency department course: Zosyn, clinda, vancomycin, heparin drip, 2 L normal saline, ASSESSMENT/PLAN: Acute on chronic hypoxemic respiratory failure secondary to COVID-19 pneumonia -patient on 3 L nasal cannula at baseline and currently on high-flow at 15 liters and 60 percent -Decadron -remdesivir -supportive care with antitussives and Tylenol -p.r.n. albuterol -continue patient's home inhalers as able.  Some not on formulary.  See if family can bring in in a.m. -telemetry and continuous pulse ox -daily CRP, D-dimer, CMP, complete blood count -patient requires inpatient admission for his high oxygen needs and daily lab monitoring for hepatotoxicity related to remdesivir use.   Acute pulmonary emboli -no intervention per emergency department providers discussion with Interventional Radiology -continue heparin drip -obtain echocardiogram in a.m. -trend additional troponins now  -Obtain baseline EKG   Abnormal UA -no urinary symptoms   Groin cellulitis -CT negative for any acute pathology -no crepitus or black in tissue noted on visual inspection. -given patient's underlying diabetes will continue with triple antibiotic coverage -continue clindamycin, Zosyn, vancomycin -p.r.n. Norco for pain -neurovascular checks of area q.4 hours.  Nursing to notify if any worsening redness or blackened tissue develops.     History Bilateral inguinal hernias -noted -no acute pathology in the abdomen noted on CT scan   Chronic obstructive pulmonary disease -see plan above for 1. And 2    AAA -no complaints of abdominal pain -continue outpatient follow-up   Hypertension Coronary artery disease status post High cholesterol -Norvasc, aspirin, Lipitor, Imdur, metoprolol, -hold Plavix while on heparin drip -hold home lisinopril secondary to elevated creatinine   BPH -continue patient's home Flomax, Proscar,cardura   Acute kidney injury Chronic kidney disease stage 3 -patient's creatinine was 2.53 in the emergency department -patient's baseline creatinine appears to be 1.24-1.6 -patient given IV fluids in the emergency department -will hold off on further IV fluids -hold nephrotoxic meds -trend with a.m. labs   Type 2 diabetes Diabetic neuropathy -hold home orally medications -switch to very low-dose corrective insulin -blood sugar was 191 on emergency department labs.  Monitor closely a scale may need to be increased with use of steroids.   Sleep apnea -continue home CPAP as able   Body mass index 36.14 -encourage caloric restriction   Code status: DNR