Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Toxic encephalopathy, Treatment noncompliance, White blood cell count decreased
Clinical narrative: Hospitalized (1.16.22 - 1.18.22); COVID-19 positive (1.12.22); Fully vaccinated -moderna x2 d/c summary:  Discharge Summary DO (Physician) ? ? Hospitalist  BRIEF OVERVIEW: Discharge Provider: DO Primary Care Provider: MD Admission Date: 1/16/2022 Discharge Date: Jan 18, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Elevated LFTs 01/18/2022 Unknown ? COVID-19 01/16/2022 Yes ? Generalized weakness 01/16/2022 Yes ? Mild mitral regurgitation 12/03/2018 Yes ? MGUS (monoclonal gammopathy of unknown significance) 02/07/2018 Yes ? Stage 3 chronic kidney disease, unspecified whether stage 3a or 3b CKD  12/07/2016 Yes ? Hypertension   Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Hypokalemia 01/18/2022 01/18/2022 Yes ? Altered mental status, unspecified altered mental status type 01/16/2022 01/18/2022  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness [R53.1] Fever, unspecified fever cause [R50.9] Altered mental status, unspecified altered mental status type [R41.82] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is an 83 year old woman who presented for evaluation of poor po intake, confusion and weakness. She had a recent diagnosis of COVID-19 on 1/12/21 but had been doing well up until 24-hours prior to admission. In the ER, she was found to be febrile but she was saturating well. CTH was negative for acute changes but showed chronic findings. Chest xray showed subtle parenchymal opacity on the right. PCT was elevated. She was diagnosed with secondary bacterial pneumonia; started on Rocephin/Azithromycin. Patient's confusion was felt to be secondary to toxic/metabolic encephalopathy.    Clinically, patient improved and was eager to go home. PT/OT cleared her for d/c home with home therapy. She will transition to Omnicef and PO Azithromycin to complete treatment for pneumonia. Discharge instructions were printed and explained.   Other medical problems addressed:  History of HTN: Holding Ziac, bp has been stable off this medication. Continue Norvasc and Lisinopril.   Hypokalemia: replaced; repeat labs outpt  Normocytic anemia: Hb lower than baseline but stable. No active bleeding. Monitor. (history of MGUS)   Hyperglycemia: no history of DM2, repeat bmp to evaluate in 1 week. Consider checking a1c.   Monitor progression of forgetfulness outpatient, likely has underlying dementia BP 133/64  | Pulse 101  | Temp 37.1 °C (Oral)  | Resp 22  | Ht 1.575 m  | Wt 51 kg  | SpO2 98%  | BMI 20.56 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing or diaphoretic.  HENT:     Mouth: Mucous membranes are moist.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Slightly tachycardic and regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing or rales.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No swelling or tenderness.  Skin:    General: Skin is warm.     Coloration: Skin is not jaundiced.     Findings: No bruising.  Neurological:     General: No focal deficit present.     Mental Status: She is alert.     Comments: aox2   H&P:CHIEF COMPLAINT: COVID-19     ASSESSMENT / PLAN: COVID 19 viral infection Suspected 2/2 bacterial CAP -continue azithro/rocephin -blood cultures collected in ED -legionella/strep urine ag -monitor for ongoing fevers Stage 3 CKD -creatinine at baseline HTN -uses amlodipine prn at home -continue daily here  Weakness -pt/ot Metabolic encephalopathy 2/2 febrile illness -improved patient AOx2,(doesn't know month) -continue to monitor -holding nightly xanax for now GERD -famotidine HLD -statin Subjective  HISTORY OF PRESENT ILLNESS: Patient is a 83 y.o. female who presents today with confusion, weakness. Patient was diagnosed with COVID 19 on 1/12. Patient had been doing alright at home until the last 24 hours. Son called EMS today because patient was refusing medications and wouldn't eat. She also was very confused and couldn't walk. Son had to carry her to the restroom to go to the bathroom. Patient is not hypoxic. Patient states she isn't eating well due to ill-fitting bottom dentures.    In the ED she was febrile, procal came back elevated at 2. She was started on rocephin and given 2L IVF. Patient currently feels improved after these therapies.  Review of Systems Constitutional:  Positive for activity change, fatigue and fever.  HENT: Negative for trouble swallowing.  Eyes: Negative for visual disturbance.  Respiratory:  Negative for shortness of breath.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for abdominal pain and trouble swallowing.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Negative for falls.  Neurological:  Positive for weakness.       Confusion Endo/Heme/Allergy:  Negative for adenopathy.  Skin:  Negative for changed spots.  OBJECTIVE: BP 144/60  | Pulse 68  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.575 m  | Wt 51.8 kg  | SpO2 95%  | BMI 20.89 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema.  Eyes:     Extraocular Movements: Extraocular movements intact.     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 or rales.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No swelling or tenderness.  Skin:    General: Skin is warm.     Coloration: Skin is not jaundiced.     Findings: No bruising.  Neurological:     General: No focal deficit present.     Mental Status: She is alert.     Comments: No longer disoriented aox2