Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Hypotension, Left ventricular failure, Lethargy, Metabolic function test abnormal, Muscular weakness
Clinical narrative: Hospitalized (5.16.22 - 6.7.22); COVID-19 positive (5.15.22); fully vaccinated PLUS Booster- pfizer x3 Discharge Summary  HOSPITALIST                                                  Discharge Information: Discharge Provider: MD  Primary Care Provider : DO  Procedures to be scheduled by PCP: None  Results/Procedures requiring PCP followup: None  Admission Date: 5/16/2022 Discharge Date: 06/07/2022  Admitting Diagnoses: Cirrhosis  Discharge Diagnoses: Active Hospital Problems   Diagnosis Date Noted POA ? Generalized weakness 04/13/2022 Yes ? Cirrhosis 02/15/2021 Yes ? Multiple wounds of skin 05/18/2022 Yes ? Cognitive communication deficit 05/17/2022 Yes ? Persistent atrial fibrillation 02/11/2020 Yes ? COVID-19   CONDITION ON DISCHARGE: Stable and improved PROCEDURES: paracentesis, peritoneal catheter insertion CONSULTATIONS: None   Details of Hospital Stay PRESENTING PROBLEM:  Hyponatremia [E87.1]   HOSPITAL COURSE: Patient is a 78 y.o. male who presents today with a history of AFib, chronic obstructive pulmonary disease, coronary artery disease, heart failure, CKD.  Patient presented to the emergency department early Sunday morning because of generalized weakness and fall causing laceration to left leg.  Patient did have laceration sutured.  Patient decided to go home because he had hospice appointment for Monday 5/16 scheduled.  Patient then return to emergency department because he fell twice and called EMS.  Patient did complain of extreme fatigue and generalized weakness.  Upon arrival to the emergency department patient was found to be hypotensive.  He was given 1 L bolus of normal saline.  Complete blood count did not show any signs of leukocytosis.  CMP did show hyponatremia at 1:16 a.m., potassium level 6.3.  Patient generally is around 5.5 for potassium level.  Creatinine is around baseline, lactic acid normal.  UA was without infection.  Patient did test positive for COVID-19.  EKG showed prolonged QTC he was given 1 g of IV calcium gluconate and started on albuterol 10 mg nebulizer.  Lasix was held due to hypotension.  Patient was given 6 mg dose of IV Decadron due to COVID-19.  Blood pressures did improve with maps greater than 65. Hospitalist services was contacted and accepted patient for admission due to electrolyte imbalances, generalized weakness and COVID-19.  Patient was admitted and over the next 2 weeks we were able to bring his sodium and potassium under good control.  He underwent to different paracenteses with Interventional Radiology.  It became apparent that the patient's cognitive status was poor and that he was not capable of living alone.  Discussions were held with his family regarding placement and Care Management has endeavor to find suitable long-term care.  Patient and family elected to pursue comfort measures only and so we stopped checking labs and concentrated on comfort.  Interventional radiology performed 1 final paracentesis and placed a peritoneal drain.  Care management contacted the facility and they are helping to facilitate placement at a facility.   Patient underwent another drainage from his peritoneal catheter on 6/6 with removal of 4550mL.  Care management was able to obtain placement at a SNF  and arrangements were made for him to transfer there with plans for hospice on discharge.  He was transferred in stable condition for continued care. PHYSICAL EXAM ON DISCHARGE:  BP 113/54  | Pulse 107  | Temp 36.9 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 73.5 kg  | SpO2 93%  | BMI 25.37 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress. Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Neurological:     Mental Status: He is alert.    5/16/22 H&P:   CHIEF COMPLAINT: Hyponatremia ASSESSMENT/PLAN: Principal Problem:      Hyponatremia Active Problems:   Hyperkalemia   Generalized weakness   Stage 3 chronic kidney disease    Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure   COVID-19   Persistent atrial fibrillation  Hyponatremia Assessment & Plan Patient's sodium level has trended lower.  On 04/26 sodium was 130, on 05/02 sodium 125, on 05/07 sodium was 121. Today patient's sodium was 116. Plan- normal saline infusion at 75 mL an hour -1 g sodium chloride tablet 3 times a day -BMP q.4 hours -2000 mL fluid restriction -routine vital signs -goal to raise sodium 4-6 mEq/L over first 24hrs.  Hyperkalemia Assessment & Plan      Patient's potassium level was 6.3 in emergency department.  Patient was given 1 g calcium carbonate and 10 mg albuterol nebulizer in emergency department. Plan:-trend BMP -continuous cardiac monitoring -routine vital signs -consider Lasix, albuterol, insulin for hyperkalemia depending on patient's renal function and blood pressure.   Generalized weakness Assessment & Plan Patient has had increased weakness.  Fell on 05/15/2022 and presented to emergency department with laceration of left lower extremity.  Seven sutures were placed.  And discharged.  Patient returned to emergency department later that same day feeling lethargic and hypotensive.  Was supposed to have hospice meeting on Monday 5/16. Plan:-PT/OT consult  -care management consult -see if hospice can meet with patient while admitted   Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure  Assessment & Plan Most recent echo showed LVEF in February 2021 at 40%. Plan:- strict I&Os -gentle hydration due to hyponatremia -continue torsemide -routine vital signs -heart healthy diet with 2000 mL fluid restriction daily. -trend BMP   Stage 3 chronic kidney disease Assessment & Plan Creatinine 2.27, GFR 28, BUN 51 Plan:-gentle hydration -avoid nephrotoxins -trend BMP for renal function   COVID-19 Assessment & Plan Patient presented to the emergency department today with increased weakness and lethargy.  COVID-19 PCR tested positive. Plan:-IV Decadron day 2 of 10 -p.r.n.  Tessalon - Mucinex   Persistent atrial fibrillation  Assessment & Plan Patient currently in AFib per EKG. Plan:-routine vital signs -81 mg aspirin -Lovenox -metoprolol for heart rate control HISTORY OF PRESENT ILLNESS: Patient is a 78 y.o. male who presents today with a history of AFib, chronic obstructive pulmonary disease, coronary artery disease, heart failure, CKD.  Patient lives at home alone but states his son lives about 1 block away and comes to see him frequently.  Patient presented to the emergency department early Sunday morning because of generalized weakness and fall causing laceration to left leg.  Patient did have laceration sutured.  Patient decided to go home because he had hospice appointment for Monday 5/16 scheduled.  Patient then return to emergency department because he fell twice and called EMS.  Patient did complain of extreme fatigue and generalized weakness.  Upon arrival to the emergency department patient was found to be hypotensive.  He was given 1 L bolus of normal saline.  Complete blood count did not show any signs of leukocytosis.  CMP did show hyponatremia at 1:16 a.m., potassium level 6.3.  Patient generally is around 5.5 for potassium level.  Creatinine is around baseline, lactic acid normal.  UA was without infection.  Patient did test positive for COVID-19.  EKG showed prolonged QTC he was given 1 g of IV calcium gluconate and started on albuterol 10 mg nebulizer.  Lasix was held due to hypotension.  Patient was given 6 mg dose of IV Decadron due to COVID-19.  Blood pressures did improve with maps greater than 65. Hospitalist services was contacted and accepted patient for admission due to electrolyte imbalances, generalized weakness and COVID-19. OBJECTIVE: Review of Systems Constitutional:  Positive for activity change and chills. Negative for fever.  HENT: Positive for rhinorrhea. Negative for congestion.  Eyes: Positive for redness. Negative for eye discharge and visual disturbance.  Respiratory:  Negative for cough, wheezing and shortness of breath.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Positive for falls and edema. Negative for joint pain and muscle pain.  Neurological:  Positive for dizziness and weakness. Negative for headaches, 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 wound. Negative for rash.   BP 95/56  | Pulse 68  | Temp 36.8 °C (Oral)  | Resp 15  | Ht 1.702 m  | Wt 73.5 kg  | SpO2 100%  | BMI 25.37 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      Appearance: Normal appearance.  HENT:    Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:    Rate and Rhythm: Normal rate. Rhythm irregular.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:    Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:    General: Abdomen is flat. Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:       General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:   General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: Bruising and laceration present.  Neurological: General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:    Mood and Affect: Mood normal.        Behavior: Behavior is cooperative