Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Hyponatraemia, Hypophagia, Immature granulocyte count, Implantable defibrillator insertion, Inflammatory marker increased
Clinical narrative: Hospitalized (12.1.21 - 12.3.21); COVID-19 positive (11.30.21); Fully vaccinated x2 with moderna  CHIEF COMPLAINT: Weakness     Assessment/Plan    ASSESSMENT / PLAN: COVID-19 virus infection Assessment & Plan -She is vaccinated; vague on start of s/s -Sounds like about 5 days ago started having fatigue, malaise -She presented last night for lower abd pain, found to have stercoral proctitis -She was disimpacted successfully, however continues to have weakness, fatigue -Not having SHOB, nausea, diarrhea, cough -Does feel she hasn't been eating/drinking much because nothing is good -No indication for steroids at this point -Inflammatory markers minimal elevated: dimer 790, ferritin 336, CRP 46, procalcitonin (-) -Already anticoulated on Eliquis for a-fib -Admit to obs; MAB's in am as none available at night; supportive measures; check UA     * Weakness Assessment & Plan -Multifactorial; certainly could be due to Covid -However, she also has low calcium, known systolic HF, deconditioning, CKD III -Also was just found to have stercoral proctitis yesterday, which was treated with disimpaction -Admit to obs, supportive care for Covid, careful diuresis, PT/OT, monitor for development of sepsis with hx of procitis -No indication at this time for antibiotics   Proctitis Assessment & Plan -Presented yesterday with concern of blood in stool -Hgb stable, CT ab/pelvis showed large rectal stool burden with stercoral proctitis -She was disimpacted with good relief of hard stool followed by loose -She was sent home on Augmentin -Will hold this for now, as not having abd pain, still making stool, does not appear sick -However, low threshold to initiate broad spectrum abx/blood cultures if declines, given possibility of bacteria translocation   Chronic systolic heart failure Assessment & Plan -EF in June was 27% with mod-severe global hypokinesis -She had a cardiac arrest in April, had defibrillator placed at that time -Thought to be associated with hypocalcemia -She is on Bb, ASA, statin, not on diuretics or Entresto, likely d/t CKD III/IV -CXR on presentation yesterday with some congestion, though peripherally euvolemic -She is up 6kg from weight a few months ago -Give lasix 40mg once and monitor response, may need further   Paroxysmal atrial fibrillation  Assessment & Plan -Continue Toprol, Eliquis -She is s/p ablation, amiodarone trials which led to v-tach    Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin Assessment & Plan -A1c in July was 6.7, which is more than controlled for her age -However, has been quite hyperglycemic into 500's the past few days -Unclear what her insulin regimen is -Lantus 10u HS, giving lispro 15u for 400's BGL; glucose checks q4 hrs -Update A1c   Hyponatremia Assessment & Plan -Mild at 132, expect to improve with diuresis   Hypocalcemia Assessment & Plan -Has apparently persisted since total thyroidectomy for cancer in 2013 -She actually was admitted with hyperCa 12.7 in July -At that time, she was taken of Ca supplements and calcitriol -However, she is now low at 6.9 with ionized Ca 0.86 -No evidence of myocardial irritability--give 1000mg Tums tonight -TID tomorrow as well -This may be partly why she is feeling poorly, though with her many comorbidities, is likely multi-factorial -May need to be stabilized on regimen of calictriol only to prevent extremes -Check intact PTH   Stage 3 chronic kidney disease  Assessment & Plan -Cr near baseline at 1.34, GFR 38   Coronary artery disease involving native coronary artery of native heart without angina pectoris Assessment & Plan -She is s/p triple bypass with isolation of pulmonary veins 12/2019 -Continue aspirin, statin   Hypothyroidism Assessment & Plan -Continue home levothyroxine, check TSH   Depression Assessment & Plan -Continue duloxetine   HISTORY OF PRESENT ILLNESS: Patient is a 79 y.o. female who presents today with fatigue and weakness. She has extensive PMH including CAD with CABG in 2019, cardiac arrest in April, is s/p defibrillator, systolic HF with EF 32%; also recurrent hypocalcemia since total thyroidectomy, hyothyroidism, and currently poorly controlled diabetes mellitus. She presented last night for blood in stool, was relieved of a large fecal impaction and had stable hemoglobin, but returns because she feels malaised and weak. She is Covid (+), she is vaccinated. She is normoxic on RA, no dyspnea or SHOB. She requires admission for weakness due to Covid infection, as well as correction of hypocalcemia, hyperglycemia, and likely fluid balance.  Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for fever.  HENT: Negative for congestion.  Eyes: Negative for visual disturbance.  Respiratory:  Negative for cough, shortness of breath and chest tightness.   Cardiovascular:  Negative for chest pain, orthopnea and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Negative for joint pain, muscle pain and edema.  Neurological:  Positive for weakness. Negative for loss of consciousness.  Skin:  Negative for rash and wound.          Objective    OBJECTIVE: BP 139/70  | Pulse 79  | Temp 36.8 °C (Temporal)  | Resp 30  | Ht 1.702 m  | Wt 96.2 kg  | SpO2 96%  | BMI 33.20 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed. She is not ill-appearing.     Comments: Appears chronically ill, but in no distress  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.  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: No wheezing.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.    Radiology results reviewed from the following date(s): 11/30 Lab results reviewed from the following date(s): 11/30, 12/1 No intake or output data in the 24 hours ending 12/02/21 0018  d/c summary: BRIEF OVERVIEW: Discharge Provider: Doctor Primary Care Provider at Discharge: Doctor Admission Date: 12/1/2021 Discharge Date:  12/04/2021   Active Hospital Problems   Diagnosis Date Noted POA ? Proctitis 12/01/2021 Yes ? Incomplete defecation 12/03/2021 Unknown ? COVID-19 virus infection 12/01/2021 Yes ? Hyponatremia 12/01/2021 Yes ? Chronic systolic heart failure  06/18/2021 Yes ? Hypocalcemia 04/03/2021 Yes ? Stage 3 chronic kidney disease  05/30/2020 Yes ? Weakness 05/30/2020 Yes ? Paroxysmal atrial fibrillation  03/02/2020 Yes ? Coronary artery disease involving native coronary artery of native heart without angina pectoris 02/05/2020 Yes ? Hypothyroidism 11/11/2015 Yes ? Depression 01/20/2015 Yes ? Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin  01/20/2015 Yes   Resolved Hospital Problems No resolved problems to display.   Pre-Existing Active Problems   Diagnosis Date Noted POA ? Postoperative hypothyroidism 04/16/2021 Unknown ? Prolonged QT interval 04/16/2021 Unknown ? Iron deficiency anemia 04/04/2021 Unknown ? Hyperkalemia 04/03/2021 Unknown ? SIRS (systemic inflammatory response syndrome)  04/03/2021 Unknown ? History of malignant neoplasm 03/09/2021 Unknown ? Pain in joint involving ankle and foot, unspecified laterality 03/09/2021 Unknown ? H/O three vessel coronary artery bypass 10/28/2020 Unknown ? Essential tremor 10/27/2020 Unknown ? Spinal stenosis of lumbar region 07/08/2020 Unknown ? Bradycardia 05/29/2020 Unknown ? Dyslipidemia 03/06/2020 Unknown ? Malignant melanoma of foot  01/26/2020 Unknown ? Skin cancer (melanoma)  11/29/2019 Unknown ? History of iron deficiency 05/20/2019 Unknown ? Gastroesophageal reflux disease without esophagitis 04/11/2019 Unknown ? Class 2 obesity due to excess calories without serious comorbidity with body mass index (BMI) of 37.0 to 37.9 in adult 06/07/2018 Unknown ? Diverticulitis 06/07/2018 Unknown ? Vitamin D deficiency 12/06/2017 Unknown ? Cataract 11/23/2016 Unknown ? Macular degeneration 11/23/2016 Unknown ? Sensation of lump in throat 11/11/2016 Unknown ? Candida infection 11/11/2016 Unknown ? Peripheral neuropathy 04/11/2016 Unknown ? History of diverticulitis 02/17/2016 Unknown ? Incisional hernia 07/01/2015 Unknown ? Essential hypertension 01/20/2015 Unknown ? Psoriasis 01/20/2015 Unknown ? Hypoglycemia, unspecified 01/20/2015 Unknown ? Nephrolithiasis 01/20/2015 Unknown ? Hyperlipidemia 01/20/2015 Unknown ? Osteopenia 01/20/2015 Unknown ? History of thyroid cancer 01/20/2015 Unknown ? Osteoarthritis 01/20/2015 Unknown    DISCHARGE MEDICATIONS: ? acetaminophen (TYLENOL) 325 MG tablet Take 2 tablets by mouth every 6 hours as needed for Pain. ? allopurinol (ZYLOPRIM) 100 MG tablet Take 1 tablet by mouth daily. ? amoxicillin-clavulanate (AUGMENTIN) 875-125 MG per tablet Take 1 tablet by mouth every 12 hours for 7 days. ? apixaban (ELIQUIS) 5 MG tablet Take 5 mg by mouth 2 times daily. ? [START ON 12/5/2021] ascorbic acid (VITAMIN C) 1000 MG tablet Take 1 tablet by mouth daily. ? aspirin 81 MG chewable tablet Chew 1 tablet Daily. Indications: Coronary Bypass Surgery ? atorvastatin (LIPITOR) 40 MG tablet Take 40 mg by mouth Nightly. Indications: High Amount of Fats in the Blood ? [START ON 12/5/2021] cholecalciferol (VITAMIN D3) 25 MCG (1000 UT) tablet Take 2 tablets by mouth daily. ? DULoxetine (CYMBALTA) 30 MG delayed release capsule Take 1 capsule by mouth 2 times daily. ? ferrous sulfate 325 (65 Fe) MG delayed release tablet Take 325 mg by mouth daily (with breakfast). ? insulin glargine (LANTUS SOLOSTAR) 100 UNIT/ML pen-injector Inject 20 Units under the skin nightly. ? Insulin Pen Needle (BD ULTRA-FINE MINI PEN NEEDLE 5 MM X 31G) 1 each nightly. Use to administer insulin glargine once nightly. Diagnosis: Type 2 Diabetes with hyperglycemia (E11.65) ? levothyroxine (SYNTHROID) 125 MCG tablet Take 1 tablet by mouth daily. Take on an empty stomach at least 30 minutes before food. ? lidocaine-prilocaine (EMLA) cream Apply 1 Application topically if needed for Topical Anesthesia. ? loratadine (CLARITIN) 10 MG tablet Take 10 mg by mouth daily as needed for Allergies. ? magnesium oxide (MAG-OX) 400 (241.3 Mg) MG tablet Take 1 tablet by mouth daily (with breakfast). Indications: Nutritional Support ? metFORMIN (GLUCOPHAGE) 500 MG tablet Take 1 tablet by mouth 2 times daily (with meals). ? metoprolol succinate-XL (TOPROL-XL) 50 MG 24 hr tablet Take 75 mg by mouth 2 times daily. 75 mg = 1 & 1/2 tablets ? OLANZapine (ZYPREXA) 5 MG tablet Take 5 mg by mouth nightly. Also takes 2.5 mg daily ? OLANZapine (ZYPREXA) 5 MG tablet Take 2.5 mg by mouth daily. Also takes 5 mg nightly ? polyethylene glycol (MIRALAX) 17 g packet Take 17 g by mouth daily as needed for Constipation. ? psyllium (METAMUCIL) 28 % packet Take 1 packet by mouth daily.    Active Issues Requiring Follow-up Needs follow-up for blood sugars   Also would benefit by outpatient cardiac evaluation due to her cardiomyopathy.  Ace and arbs were held due to mild renal insufficiency   DISCHARGE DISPOSITION: Home with services - Nursing and Physical therapy   Future Appointments Date Time Provider Department Center 12/17/2021 12:00 PM Doctor     Appointments Needing to be Scheduled Contact information for follow-up     Medical Center   Next Steps: Follow up    Doctor Specialty: Family Medicine Relationship: PCP - General   Medical Center   Next Steps: Follow up in 5 day(s)    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness  COVID-19 virus infection COVID-19   HOSPITAL COURSE: The deli female admitted through the emergency room with generalized weakness felt to be related to COVID.  She is not hypoxic.  She is vaccinated.  COVID symptoms appear to be very mild other than the weakness.  She did not receive any antivirals however she did receive monoclonal antibodies in the emergency room.  She was seen by physical therapy and occupational therapy in hospital and at the time of her discharge she was able to ambulate and transfer from bed to chair with minimal assistance. Of significance is markedly elevated blood sugar.  We were able to control him with intermittent injections as well as Lantus.  Will discharge her on 20  units of Lantus and 500 mg of metformin 2 times a day.  We gave her glucometer.  Will rate arrangements for home health care.  Will also make arrangements for home physical therapy.   She also had a urinary tract infection she receive Rocephin in the hospital and was converted to Augmentin orally.  Cultures were positive for E coli.   She was discharged home in satisfactory condition.  This was discussed with her son.  We did discuss ECF placement for physical therapy however he wants to have her home   CONSULTS / RECOMMENDATION: PTOT  INPATIENT PROCEDURES: None  BP 129/71  | Pulse 61  | Temp 36.4 °C (Oral)  | Resp 14  | Ht 1.702 m Comment: per pt | Wt 94.8 kg  | SpO2 100%  | BMI 32.73 kg/m²    Physical Exam Constitutional:      Appearance: She is well-developed.  HENT:     Head: Normocephalic.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Rhythm irregular.  Pulmonary:     Breath sounds: Normal breath sounds.  Abdominal:     General: There is no distension.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No tenderness or deformity.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Motor: Weakness (Generalized) present.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.    PERTINENT LABS AND STUDIES: Lab Results Last 72 Hours