Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Urinary sediment present, Urine analysis, Urine analysis abnormal, Urine ketone body absent, Urobilinogen urine increased
Clinical narrative: admission History and Physical Date of Service Jul-05-2022 0942  Chief Complaint Weakness, trouble breathing  HPI / Subjective 95-year-old female with history of  COPD, nocturnal hypoxia.   as noted previously the patient was feeling run down the last couple of days, more weak than normal and some trouble with her mobility.  she thinks that she has been feeling run down now for 2-3 weeks but acutely worse last couple of days.  Admits to fever measured at 101 degrees F. tested positive for COVID-19 with home test.  Came in overnight and was placed on observation without confirmatory PCR COVID test.   07/05/2022-patient is feeling better than 07/04/2022.  Slightly less weak, still short of breath with ambulation.  She does live at home by herself typically but her ADLs have been limited lately.  Her son did visit the room while I was speaking with her and stated that the patient could stay with him after she gets out of the hospital.  She has no other new complaints or issues.  Past Medical History Bilateral glaucoma  Osteoarthritis  Chronic obstructive lung disease  Past Surgical History Decompression of median nerve, Left in 2021  Immunization History received booster of Pfizer COVID-19 vaccination, 06/28/2022  Home Medications albuterol sulfate 2.5 mg/0.5 mL nebu Dose: INHALATION 3 TIMES A DAY AS NEEDED  ASPIRIN EC Dose: 81 MG ORALLY ONCE A DAY  BRIMONIDINE TART 0.2% OPHTH 5 ML Dose: 1 GTT OPTHALMIC TWICE DAILY  Colace Oral Capsule 100 MG Dose: 100 MG ORALLY TWICE A DAY AS NEEDED  CYANOCOBALAMIN Dose: 2500 MCG ORALLY ONCE A DAY  Diclofenac-miSOPROStol Oral Tablet Delayed Release 50-0.2 MG Dose: 50 MG ORALLY TWICE DAILY  FAMOTIDINE Dose: 20 MG ORALLY TWICE DAILY  Ferrous Gluconate Oral Tablet 324 (38 Fe) MG Dose: 1 TAB ORALLY 3 TIMES A DAY  Gabapentin Oral Capsule 100 MG Dose: 100 MG ORALLY 3 TIMES A DAY  MiraLax Oral Packet Dose: 1 PKT ORALLY ONCE A DAY AS NEEDED for CONSTIPATION  Omeprazole Oral Capsule Delayed Release 20 MG Dose: 20 MG ORALLY ONCE A DAY  PreserVision AREDS 7,160-113-100 unit-mg-unit tab Dose: ORALLY TWICE DAILY  traMADol HCL 50 MG Dose: 1 TAB ORALLY EVERY 6 HOURS AS NEEDED  Vitamin D3 2,000 unit cap Dose: 1 CAP ORALLY ONCE A DAY  Allergies Tetracyclines & Related - Not Specified  Social History tobacco use Never Smoked, Smoking Cessation Not Applicable  marital status Widowed  lives at home solo 07/05/2022  Family History parents Father Deceased  Malignant neoplastic disease Colon  Mother Deceased Heart disease  Mother Deceased  Unknown problems  Primary Care Provider (name withheld)  REVIEW OF SYSTEMS Constitutional:  admits to recent fever.  Denies chills.  Skin: Denies itching, rashes, or open wounds.  Eyes: Denies vision changes, eye pain, or eye discharge.  ENT:   Admits to chronic hearing problems with hearing aids.Denies sinus problems, or sore throat.  Cardiovascular:   Admits to fatigue.Denies chest pain, palpitations, edema  Respiratory: Denies coughing, wheezing.   Admits to dyspnea with exertion  GI: Denies abdominal pain, nausea, vomiting, constipation, or diarrhea.  GU: Denies dysuria, hematuria, increased urinary frequency, or genital lesions.  Musculoskeletal: Denies specific arthralgias, myalgias, or difficulty with mobility.  Neurologic: Denies confusion, numbness, or tingling in extremities.  Psych: Denies anxiety, depression, suicidal thoughts, or homicidal thoughts.  Heme: Denies easy bruising, history of blood clots, or anemia.  Immunologic: Denies recurrent infections, history of anaphylaxis or environmental allergies.  Systems Reviewed All systems reviewed and negative except as noted above  Vital Signs Jul-05-2022 0723 T 97.9 HR 80 RR 19 BP   117 / 67 O2Sat 95 Jul-05-2022 0430 T 97.6 HR 78 RR 17 BP   138 / 71 O2Sat 99 Intake and Output previous day current day encounter cumulative Intake 740 ? 740 Output 1901 ? 1901 Diff (I-O) (-1161) ? (-1161) PHYSICAL EXAM constitutional: Acute on chronically ill-appearing, appears of stated age.   Eyes: Pupils are equal, round, and reactive to light. Sclerae are white. Conjunctivae are mildly injected without pallor.  ENT: Hearing is grossly intact , although mildly impaired bilaterally. Oral mucosa is moist. There is no pharyngeal erythema. The thyroid is not enlarged and is non-tender.  Cardiovascular:  regular rate and rhythm except when the patient just sat down after ambulating had bigeminy of PVCs.  Resolved with rest and supplemental oxygen, 2 L.  Respiratory:  lungs have coarse breath sounds bilaterally.  Patient is using 2 L supplemental oxygen via nasal cannula.  SpO2 87% on room air, improves with ambulation.  Also improves supplemental oxygen, 2 L.  GI: Abdomen is without lesion. Bowel sounds are normoactive in all quadrants. Abdomen is soft, non-tender, and non-distended. No organomegaly appreciated on palpation.  GU: There are no visible lesions on the external genitalia. No hernias were appreciated  Musculoskeletal/osteopathic: Range of motion in the shoulders, elbows, hips, and knees is grossly intact.  patient is ambulatory but  stamina has decreased.  Patient does get weak after walking around the room 20 ft.  Neurologic: Cranial nerves 2-12 are grossly intact.  Sensation to light touch is intact in upper and lower extremities.  Psych: The patient is alert and oriented to place, month and person. The patient's insight and judgment appear intact. The patient's mood is euthymic. The patient's affect is appropriate. Patient is calm.  Heme: There is no bruising on the face or extremities. Homans sign is negative bilaterally. There is no blood in the external nares.  Lab Results Jul-05-2022 0515 Chemistry GLUCOSE  104BUN  12CREAT  0.7MDRD GFR  78NA  142K  4.1CL  104CALCIUM  8.6ALK PHOS  95CO2  31.6AST  38ALT  37AST/ALT  1.0TL PROT  6.9ALBUMIN  2.9TBILI  0.2OSMO  283.2ANION GP  10.5BUN/CRE  17.1FERRITIN  192MAGNESIU  2.2 Jul-05-2022 0515 Coagulation D-DIMER  1.59 Jul-05-2022 0515 Hematology WBC  7.0RBC  4.37HGB  12.2HCT  38.3MCV  87.6MCH  27.9MCHC  31.9RDW  14.0PLT  287MPV  9.0 Jul-05-2022 0515 Serology PROCALC  1.69 Jul-05-2022 0045 Urinalysis Department SPECGRAV  <=1.005U-PH  6.0LEUCOCYT  TraceNITRITES  NegativePROTEIN  NegativeGLUCOSE  NegativeKETONES  NegativeUROBILIN  0.2BILRUBIN  NegativeBLOOD  NegativeCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  NCULTIND  Not IndicatedWBC  0-2RBC  0-2SQUAM EP  0-2BACTERIA  NoneMUCUS  3+ Jul-04-2022 1750 Rad 1610163   Jul-04-2022 1615 Chemistry GLUCOSE  121BUN  17CREAT  0.7MDRD GFR  78NA  134K  4.0CL  97CALCIUM  8.3ALK PHOS  108CO2  27.9AST  14ALT  25AST/ALT  0.6TL PROT  6.6ALBUMIN  3.2TBILI  0.3OSMO  271.0ANION GP  13.1BUN/CRE  24.3LACTATE  0.70TROPI-HS  11 Jul-04-2022 1615 Hematology WBC  10.3RBC  4.12HGB  11.6HCT  35.1MCV  85.2MCH  28.2MCHC  33.0RDW  13.8RDWSD  43.1PLT  280MPV  9.3AUTONEU%  92.3AUTOLYM%  2.8AUTOMON%  3.8AUTOEOS%  0.3AUTOBAS%  0.5AUTONEU#  9.5AUTOLYM#  0.3AUTOMON#  0.4AUTOBAS#  0.1AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.03IG%  0.3 Imaging Results Chest x-ray supports COVID-19 pneumonia.  Possible right lower lobe consolidation that could be bacterial in origin.  Plan Assessment:  -Acute on chronic hypoxic respiratory failure  secondary to COVID-19 pneumonia and possible superimposed bacterial pneumonia - likely superimposed bacterial pneumonia, right lower lobe - COVID-19 pneumonia, supported with chest x-ray,  subjective home test -  profound weakness and debility, acute - COPD,  not in acute exacerbation from a respiratory standpoint - history of essential hypertension - history of osteoarthritis - history of bilateral glaucoma  Plan: We will admit the patient inpatient as the procalcitonin is 1.69 today supporting a superimposed bacterial pneumonia on top of the COVID-19 pneumonia. medical status.  Start ceftriaxone, azithromycin to cover atypical bacteria.  Continue steroids.   COVID-19 circ as well as Gram labs have been ordered to calculate ongoing risk.  Breathing treatments have been ordered including Dulera, albuterol.    We will monitor her O2 requirement, have her work with physical therapy and order for nutrition consult.  Justification for Hospitalization Please document severity of illness/comorbidities and intensity/duration of the treatment to justify hospitalization (  Acute on chronic hypoxic respiratory failure)  HEALTHCARE PROXY/AGENT Name: [ ] Relationship: [ ] Contact Info: [ ]  Advanced Care Planning Discussion Date: [ ]  Individuals Present: [ ]  ORGAN or TISSUE DONATION [ ]  RELIGIOUS/CULTURE CUSTOMS OR PREFERENCES [ ]  FORMS ON FILE [Living Will/Durable power of attorney for health care/POLST/MOLST/Other advance care planning documents]  TIME SPENT [ ] Minutes  Electronically signed by RESIDENT on Jul-05-2022 1007