Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Fibrin D dimer normal, Full blood count, Glomerular filtration rate, Granulocyte percentage, Haematocrit normal
Clinical narrative: Hospitalized (1.30.22 - 2.2.22); COVID-19 positive (1.30.22); Fully vaccinated -J&J - x1 Discharge Summary   BRIEF OVERVIEW:   Admit Date: 1/30/2022  6:25 PM Discharge Date: 2/2/2022  6:02 PM    Admitting Physician:  (privacy), MD Attending Physician: (privacy),  MD, MPH Discharge Clinician:  (privacy),  MD, MPH Primary Care Provider at Discharge: (privacy),  MD   DETAILS OF HOSPITAL STAY:   Admission Diagnosis (per H&P) Acute Hypoxic Respiratory Insufficiency COVID-19 PNA Nausea/Vomiting/Diarrhea, likely related to COVID-19 HTN Hx lung adenocarcinoma s/p LUL resection 2/2021 Right upper lobe opacity on CT 1/30/21 CAD   Discharge diagnosis Acute hypoxic respiratory failure  COVID-19 pneumonia  Essential hypertension  Hx lung adenocarcinoma s/p LUL resection 2/2021 Right upper lobe opacity on CT 1/30/21 Hoarseness CAD ETOH abuse Acute severe malnutrition   Hospital Course:  Patient is a 76 y.o. male with past medical history significant for hypertension and lung cancer who presented with nausea/vomiting and diarrhea causing inability to eat. Pt reports having COVID-19 symptoms for about 2-3 weeks.    Upon arrival to the ED, COVID-19 test was performed and was found to be positive. Initial spO2 noted to be 89% and pt was placed on 2L NC.  EKG performed showed NSR with PACs and no acute ischemic changes. CTA thorax was was negative for PE but showed b/l groundglass opacities.  Patient was admitted and was continued on dexamethasone.  Patient's oxygen saturations remained stable.  Patient received 4 days of dexamethasone.  Patient also had hoarseness of voice which family wanted workup done in the hospital.  Patient and family were advised to follow-up with ENT outpatient.   Patient also had right upper lobe mass and was advised to follow-up with his hematologist on outpatient basis if further workup is needed.  Patient otherwise was stable on 2 L for supplemental oxygen.  Pulmonary Rehab was consulted to arrange for home oxygen and patient was discharged home in stable condition.   Consults: IP CONSULT TO NUTRITION IP CONSULT TO PULMONARY REHAB   Operations/Procedures: Surgery and Procedures    None BP 131/83  | Pulse 83  | Temp 36.6 °C (Axillary)  | Resp 18  | Ht 1.753 m  | Wt 75 kg  | SpO2 90%  | BMI 24.42 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is not diaphoretic.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.  Neurological:     Mental Status: He is alert.  1/30/22 H&P:  CHIEF COMPLAINT: Pneumonia due to COVID-19 virus ASSESSMENT / PLAN: Acute Hypoxic Respiratory Insufficiency COVID-19 PNA - initially spO2 89% on room air, now on 3L NC with spO2 91% - decadron 6mg daily x 10 days; no remdesivir d/t symptoms of 2-3 weeks - CTA thorax: negative for PE, b/l groundglass opacities - continuous pulse ox, encourage IS - check CRP/D-dimer - monitor labs/VS   Nausea/Vomiting/Diarrhea, likely related to COVID-19 - encourage PO intake, antiemetics PRN - nutrition consulted   HTN - pt takes Norvasc 10 mg as needed for high blood pressure - BP stable currently will monitor and restart norvasc if needed   Hx lung adenocarcinoma s/p LUL resection 2/2021 Right upper lobe opacity on CT 1/30/21   - CT notes similar in appearance to 9/7/2021 exam involving the right upper lobe, and measures 3.3 x 1.7 cm   - per encounter records pt follows with pulmonary and declined biopsy of RUL mass like area   CAD - stress MPI 12/2020 with no evidence of ischemia   DVT ppx - lovenox FULL CODE HISTORY OF PRESENT ILLNESS: Patient is a 76 y.o. male with PMH HTN, lung Ca who presents today with nausea/vomiting and diarrhea causing inability to eat. Pt reports having COVID-19 symptoms for about 2-3 weeks, he lives with his wife and daughter and his daughter had tested positive previously. Pt reports cough, occasional fever/chills, nausea/vomiting and diarrhea x 1 week. He denies sore throat, chest pain, shortness of breath, leg swelling, headaches, falls. Pt reports weakness and weightloss.    Upon arrival to the ED, COVID-19 test was performed and was found to be positive. Initial spO2 noted to be 89% and pt was placed on 2L NC. Labs were performed which revealed trop 28 -> 24, Chloride 94, and BUN 23. EKG perforedm showed NSR with PACs and no acute ischemic changes. CTA thorax was performed which was negative for PE but showed b/l groundglass opacities. Pt was administered 6 mg decadron. Pt admitted to the hospital for further management Review of Systems Constitutional:  Positive for chills, fatigue, fever and unexpected weight change.  HENT: Negative for sore throat and trouble swallowing.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough. Negative for shortness of breath.   Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Positive for nausea, vomiting and diarrhea. Negative for abdominal pain, blood in stool and trouble swallowing.  Genitourinary:  Negative for difficulty urinating.  Musculoskeletal:  Negative for falls.  Neurological:  Positive for weakness. Negative for headaches.  Skin:  Negative for rash and wound  OBJECTIVE: BP 138/84  | Pulse 86  | Temp 36.9 °C (Oral)  | Resp 22  | Ht 1.753 m  | Wt 75 kg  | SpO2 90%  | BMI 24.42 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress. HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. No friction rub. No gallop.   Pulmonary:     Breath sounds: No wheezing, rhonchi or rales.     Comments: Diminished b/l Abdominal:     General: Abdomen is flat. Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.