Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Vomiting, Walking aid user, White blood cell count decreased
Clinical narrative: Date of Service Jul-15-2022 0937  Addendum   I personally visited with the patient and the Resident physician  and reviewed the chart components, visited with and examined this patient ,discussed the plan of care    Electronically signed on Jul-17-2022 0810 Date of Admission Admit Date: Jul-12-2022  Date of Discharge Date of discharge Jul-15-2022 @ 1200  Allergies Penicillins - Not Specified  Chief Complaint Vomiting, dehydration  Final Diagnoses resolved  Hyperglycemia Resolved Jul-15-2022  Dehydration Resolved Jul-15-2022  Supraventricular tachycardia Resolved Jul-15-2022  Procedure(s) Performed None  Lab Results Jul-15-2022 0818 Rad  Jul-15-2022 0500 Chemistry GLUCOSE  196BUN  24CREAT  0.9MDRD GFR  62NA  144K  3.5CL  114CALCIUM  7.8ALK PHOS  66CO2  19.0AST  81ALT  51AST/ALT  1.6TL PROT  5.0ALBUMIN  2.5TBILI  0.3DBILI  0.1OSMO  296.3ANION GP  14.5BUN/CRE  26.7 Jul-15-2022 0500 Hematology WBC  6.1RBC  3.43HGB  10.1HCT  29.2MCV  85.1MCH  29.4MCHC  34.6RDW  14.9RDWSD  46.2PLT  74MPV  11.5AUTONEU%  82.3AUTOLYM%  11.8AUTOMON%  5.1AUTOEOS%  0.0AUTOBAS%  0.0AUTONEU#  5.0AUTOLYM#  0.7AUTOMON#  0.3AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.05IG%  0.8 Jul-15-2022 0500 Serology PROCALC  7.91 Jul-14-2022 2046 Point Of Care GLUSTX  223 Jul-14-2022 1701 Point Of Care GLUSTX  246 Jul-14-2022 1214 Point Of Care GLUSTX  182 Imaging Results One view chest x-ray 7/13/22 Impression: Mild bibasilar atelectasis.  Echocardiogram 7/13/22  Conclusions: Normal left ventricular systolic function with LVEF >60% Borderline left atrial enlargement. Normal appearance and function of the mitral valve with trace physiologic regurgitation.  Mild to moderate mitral regurgitation.  Mild aortic stenosis (AVA > 1.5cm2).  Severe aortic regurgitation.  The estimated peak RVSP is 0mmHg.  One view chest x-ray 7/15/22 Impression:   Small bilateral pleural effusions, mildly increased in size.  Interval increase in mild bibasilar pulmonary opacities.  Functional Status* Impaired mobility (uses walker)  Mental Status* Normal Cognition  Social History tobacco use Never Smoked, Smoking Cessation No NON SMOKER  marital status Single  Health Concerns Pneumonia  Urinary tract infectious disease  Supraventricular tachycardia  Dehydration  Hyperglycemia  Vital Signs Jul-15-2022 0331 T 98.5 HR 73 RR     27 BP   105 /     54  O2Sat 93 Jul-15-2022 0040 T 98.3 HR 71 RR     26 BP       94  / 57 O2Sat 93 PHYSICAL EXAM CONSTITUTIONAL: Patient appears comfortable and in no acute distress. CARDIOVASCULAR: Heart has regular rate rhythm, pulses are 2/2 in the upper extremities, no edema noted RESPIRATORY: Lungs clear to auscultation throughout and respiratory effort is non-labored GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive NEUROLOGICAL: Patient is alert and oriented to person, place, time, and event. Sensation is grossly intact PSYCHIATRIC: Patient's mood is euthymic, affect is appropriate. RASS of 0.  Consultations None  Hospital Course Patient is a 68-year old female who presented to the ER by personal vehicle with 1 day history of vomiting. The following history was obtained from her sister who is present in the room and her DPOA. The patient is considered a poor historian based on history of subdural hematoma.  Her baseline now is AO x2 and requires assistance with her ADLs.  The symptoms began approximately 0230 7/12/22.  The patient called her sister at around 0600 and stated that she did not feel good and asked her sister to bring her some sprite.   Her sister received another call from patient's caregiver at 1230 that patient was not responding to her knocking on the door.  Patient's sister went over to the house and unlocked the door.  Based on continuous vomiting since morning patient's sister made decision to bring patient into the ER.    Patient received fluid resuscitation in the ED with 3L NS.  She was then started on maintenance fluids at 75cc/hr for the duration of her stay.  UA returned positive the night of her admission and she was started on ceftriaxone at that time.  Her second day of admission her procalcitonin spiked and there was concern for aspiration pneumonia based on history, labwork, and imaging.  At that time metronidazole was added to her ceftriaxone therapy for coverage of UTI and possible pneumonia.  Patient's oxygen requirements continued to be titrated down during her stay with her being back on room air by morning of 7/15/22.  Patient was found to be COVID positive upon admission and based on increased oxygen demand Remdesivir and dexamethasone treatments were started the night she was admitted.  She received daily dosing and tolerated these treatments well.   Patient was in SVT upon admission and was started on a diltiazem drip in the ED.  Diltiazem was effective in controlling her heart rate and she was titrated down through her first night of admission.  By noon the afternoon of 7/13/22 she had been titrated off of the drip and her heartrate has remained sinus in the low 80s.  Based on initial presentation patient met SIRS criteria in ED.  With source of infection patient was deemed to be in severe sepsis with a lactate of 6.8.  Sepsis protocol was initiated.  Patient received adequate hydration and blood cultures returned negative during her stay.  Patient's vitals were stable from 7/13/22 on.  Condition at Discharge Stable  Discharge Medications Amantadine HCl Oral Capsule 100 MG 100 MG ORALLY TWICE DAILY aspirin 81 mg TbEC 1 TAB ORALLY ONCE A DAY atorvastatin 40 mg tab 1 TAB ORALLY ONCE A DAY Biotin Maximum Strength Oral Capsule 5000 MCG 5000 MCG ORALLY ONCE A DAY Cephalexin Oral Capsule 500 MG 500 MG ORALLY TWICE DAILY Januvia Oral Tablet 100 MG 100 MG ORALLY ONCE A DAY Lasix Oral Tablet 20 MG 20 MG ORALLY EVERY MORNING levETIRAcetam Oral Tablet 500 MG 500 MG ORALLY TWICE DAILY levocetirizine 5 mg tab 1 TAB ORALLY ONCE A DAY Melatonin ER Oral Tablet Extended Release 3 MG 3 MG ORALLY DAILY AT BEDTIME metroNIDAZOLE Oral Tablet 500 MG 500 MG ORALLY 3 TIMES A DAY NP Thyroid 90 mg tab Continue taking same as home omeprazole 20 mg TbEC 1 TAB ORALLY EVERY MORNING Pioglitazone HCl Oral Tablet 30 MG 30 MG ORALLY ONCE A DAY Senna Plus Oral Capsule 50-8.6 MG 50 MG ORALLY TWICE DAILY sertraline 100 mg tab 150 MG ORALLY ONCE A DAY Vitamin D3 Oral Capsule 250 MCG (10000 UT) 250 MCG ORALLY SUN Discharge Disposition Transfer to skilled nursing facility (SNF)  Plan ASSESSMENTS: -Severe sepsis on admission, secondary to COVID vs UTI, vs unknown infection, resolved -Supraventricular tachycardia likely secondary to COVID-19 infection, resolved -Acute hypoxic respiratory failure likely secondary to COVID-19 infection, resolved -COVID-19 infection, stable -Urinary tract infection, found on UA 7/12/22, antibiotic therapy to continue -Suspected aspiration pneumonia, stable -Acute kidney injury, Creat 1.5 and eGFR 35 on admission, likely secondary to dehydration, resolved -Elevated lactate, 6.20 on admission, likely secondary to dehydration, secondary to recent vomiting, resolved -Leukopenia, 3.9 on admission, unknown etiology, resolved -Elevated troponin, 84 on admission, likely secondary to acute heart strain, resolved -Hyperglycemia, 382 on admission, likely stress reaction to COVID infection, resoleved -Elevated hemoglobin, 18.9 on admission, likely secondary to dehydration, resolved -Dehydration, based on physical exam on admission, improving -Severe aortic regurgitation, per ECHO 7/13/22 -Mild to moderate mitral regurgitation, per ECHO 7/13/22  -Hyperlipidemia, per history, control unknown on home medications -Depression, per history, control unknown on home medications -Hypothyroidism, per history, control unknown on home medications -Diabetes Mellitus type 2, per history, control unknown on home medications -Dementia, per history, control unknown on home medications -Essential tremor, per history, control unknown on home medications -History of CVA in 2021, unknown etiology  -Debility, requiring assistance with ADLs   PLANS:  Patient to be discharged to nursing home for rehab to home.  At this time labwork and vitals are stable.  Patient is no longer requiring supplemental oxygen.  Patient discharged on one day of lasix for mild bilateral pleural effusions.    Patient discharged on keflex and metronidazole for continued antibiotic therapy for UTI and suspected pneumonia.  Patient to follow up with Dr. within one week of discharge from nursing home.  2-view chest x-ray ordered for 7/18/22.  Discharge Instructions Diet Diabetic  Activity As tolerated  Primary Care Provider  Electronically signed on Jul-15-2022 1244 I have seen and physically examined the patient on [Date of service] and agree with the documentation of [name of the resident]. I have also discussed my findings and plan of care with [name of the resident]. Any changes and additional information are listed below. Electronically signed on Jul-17-2022 0810