Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Device issue, Drug screen positive, Electrocardiogram normal, Encephalopathy, Haemoglobin decreased
Clinical narrative: Date of Admission  01/24/2022   Date of Discharge  01/25/2022   Reason for Hospitalization   pt found face down in shower, increased confusion reported per  family  Hospital Course   Patient is a 65-year-old male with a history of hypertension, DM type I, chronic pancreatitis 2/2 hypertriglyceridemia, history of renal stones, BPH on Flomax, NASH, chronic back pain with intrathecal Dilaudid pain pump, and hypogonadism on testosterone  pellets who presents to the ED via EMS after being found down. He was found to be COVID+.  Hospital course: Significant for altered mental status and tachycardia on presentation the ED.  He was given1 L bolus x3.  ECG unremarkable.  Required 2 L oxygen. Labs significant for anemia with hemoglobin of 11, hyponatremia at 129, AKI with creatinine of 1.3 (bl 1-1.2) ALT lactic acid, normal ammonia, elevated troponin at 25 with 2-hour pending, elevated BNP at 187, UDS + for opiates (Dilaudid pump), VBG with normal pH and CO2, Covid Positive, flu negative. EKG WNL. Imaging reviewed without any any acute abnormalities aside from the intrathecal portion of the pain pump wire not continuous with the subcutaneous portion.  When discussed with patient's wife, she states that this is a known issue and has been cleared by patient's pain management physician. Pt admitted to family medicine service for continued treatment and monitoring of COVID and AMS. Due to new oxygen requirement, will start dexamethasone and remdesivir for treatment of Covid.  Altered mental status and tachycardia most likely secondary to Covid. On 1/25, pt no longer requiring oxygen and is back to baseline mentation. Oriented x4. Pt stable for discharge home. Provided return precautions.  Discharge Diagnoses      #COVID 19 PNA Encephalopathy 2/2 COVID, resolved  Date of symptom onset: 1/20  Date of + test: 1/23  Quarantine until 1/26 (5 days from symptom onset), mask, if febrile cont to quarantine  DM  -Cont Home regimen: Toujeo 80 units, lispro up to 70U daily as needed  -Work on BS control outpt   Chronic back pain  Neuropathy  CT showing concern for intrathecal portion of the pain pump not continuous with subcutaneous portion, this is a known issue to patient's pain management doctor Dr.  ?cont following with pain doctor  -cont home meds  cont all home meds  Other Diagnoses   Ongoing  BENIGN ESSENTIAL HYPERTENSION  Blepharoptosis  BMI 40.0-44.9, adult  BPH loc w urin obs/LUTS  Carpal tunnel syndrome  Chronic kidney disease, stage 3a  Chronic pancreatitis  Cognitive complaints  Degenerative joint disease  Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled  Dyslipidemia  Family history of atherosclerosis  Fatigue  Insomnia  Kidney stone  Low testosterone  NASH (nonalcoholic steatohepatitis)  Osteoarthritis  Other chronic pain  Poorly control type 2 diabetes mellitus  Pure hyperglyceridemia  Removal of eye prosthesis  Severe obesity  SVT - Supraventricular tachycardia  Vitamin D imbalance  Historical  No qualifying data        Discharge Disposition  home, stable  Medications  New, Changed, or Refilled Medications  None    Medications to be Continued  Misc. Medication (One Touch Delicat See Instructions, UAD to check blood glucose levels, 400 Each, 2 Refill(s)  Instructions:UAD to check blood glucose levels  Misc. Medication (One Touch Ultra g See Instructions, use to check glucose qid, 150 Each, 6 Refill(s)  Instructions:use to check glucose qid  acetaminophen (Tylenol Extra Streng 1,000 mg, 2 Tablet(s), Oral, q6h, PRN: as needed for pain, 0 Refill(s)    amitriptyline (amitriptyline 50 mg) 100 mg, 2 Tablet(s), Oral, At Bedtime, 0 Refill(s)    cyclobenzaprine (cyclobenzaprine 10 10 mg, 1 Tablet(s), Oral, tid, PRN: Muscle Spasm    docusate (docusate sodium 100 mg) 100 mg, 1 Tablet(s), Oral, bid, PRN: as needed for constipation    ergocalciferol (ergocalciferol 50,0 See Instructions, TAKE ONE CAPSULE BY MOUTH TWICE A WEEK, 25 capsule(s), 4 Refill(s)  Instructions:TAKE ONE CAPSULE BY MOUTH TWICE A WEEK  fenofibrate (fenofibrate 200 mg) See Instructions, TAKE ONE CAPSULE BY MOUTH DAILY, 90 capsule(s), 3 Refill(s)  Instructions:TAKE ONE CAPSULE BY MOUTH DAILY  gabapentin (gabapentin 800 mg) 1,600 mg, 2 Tablet(s), Oral, bid, 0 Refill(s)    glipiZIDE (glipiZIDE 10 mg) See Instructions, TAKE TWO TABLETS BY MOUTH TWICE DAILY . NEED FOLLOW UP APPOINTMENT FOR FURTHER REFILLS., 360 Tablet(s), 3 Refill(s)  Instructions:TAKE TWO TABLETS BY MOUTH TWICE DAILY . NEED FOLLOW UP APPOINTMENT FOR FURTHER REFILLS.  hydrochlorothiazide-triamterene (hy See Instructions, TAKE 1 CAPSULE BY MOUTH ONCE DAILY. *MAKE APPOINTMENT FOR REFILLS*, 30 capsule(s), 0 Refill(s)  Instructions:TAKE 1 CAPSULE BY MOUTH ONCE DAILY. *MAKE APPOINTMENT FOR REFILLS*  ibuprofen (ibuprofen 200 mg) 800 mg, 4 Tablet(s), Oral, q8h, PRN: as needed for pain, 0 Refill(s)    icosapent (Vascepa 1 g) 0 Refill(s) Comments: Responsible Provider: NOT PROVIDED   insulin glargine (Toujeo insulin So 80 units, Subcutaneous, Daily, for 30 day(s), 1.5 mL, 11 Refill(s)    insulin lispro (HumaLOG KwikPen 100 See Instructions, INJECT UP TO 70 UNITS A DAY UNDER THE SKIN, 45 mL, 11 Refill(s)  Instructions:INJECT UP TO 70 UNITS A DAY UNDER THE SKIN  levETIRAcetam (Keppra 250 mg) 250 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 11 Refill(s)    metFORMIN (metFORMIN 500 mg) See Instructions, TAKE TWO TABLETS BY MOUTH TWICE DAILY, 360 Tablet(s), 3 Refill(s)  Instructions:TAKE TWO TABLETS BY MOUTH TWICE DAILY  morphine (Morphine Sulfate IR 15 mg 15 mg, 1 Tablet(s), Oral, q4h, PRN: for pain, 0 Refill(s)    nabumetone (nabumetone 750 mg) 750 mg, 1 Tablet(s), Oral, bid, 0 Refill(s)    simvastatin (simvastatin 20 mg) See Instructions, TAKE ONE TABLET BY MOUTH DAILY., 90 Tablet(s), 3 Refill(s)  Instructions:TAKE ONE TABLET BY MOUTH DAILY.  testosterone Pellets, Subcutaneous, 0 Refill(s)    testosterone (Testopel Pellets 75 m 1,125 mg, 15 Each, Subcutaneous, Every 6 Months, 15 Each, 0 Refill(s)    traZODone (traZODone 50 mg) 50 mg, 1 Tablet(s), Oral, At Bedtime, prescribed by Dr, 0 Refill(s)  Instructions:prescribed by Dr     Discontinued Medications  tamsulosin (Flomax 0.4 mg) 0.4 mg, 1 capsule(s), Oral, Daily, for 30 day(s), 30 capsule(s), 11 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 36.7 °C  TMIN: 36.7 °C  TMAX: 37.0 °C  HR: 78  RR: 16  BP: 136/80  SpO2: 95%      General: NAD, alert  Head: normocephalic, atraumatic  Eyes: PERRL, EOMI (prosthetic R eye)  ENT: normal hearing; moist oral mucosa; no epistaxis  Cardiovascular: RRR, normal peripheral perfusion  Respiratory: CTA bilaterally, nonlabored breathing. No rhonchi, rales, or wheezing.  GI: nondistended, nontender  MSK: no swelling or deformity noted  Skin: intact, dry, no rash appreciated  Neuro: alert, oriented x3, no focal defects  Psych: appropriate mood and affect     Follow Up Appointments      Appointment Type  When  With  Where  Contact Information  Status   05/12/2022 01:15 PM Surg Urology  Surgery Clinics   06/10/2022 11:00 AM Neurology    Nursing/Other Orders   Regular Diet. Ordered on 01/24/22 17:45:00, Meal Start Time Breakfast 0700 to 0900   Fall Precautions. 01/24/22 10:29:37. Order comment: order placed from nursing documentation CLIN_FALL_RISK   Fall Precautions. 01/24/22 17:45:00 Order comment: Assess Fall Risk Score Qday; Orientation/clarity/mental status;patient stability during ambulation/transfer (ie., gait, balance, streng ); Effectiveness of safety interventions    Activity As Tolerated. 01/24/22 17:45:00, Continuous Order   Code Status. Code Status Description: DNAR (Do Not Attempt Resuscitation)     Addendum by MD, on January 26, 2022 05:33:54 (Verified)    Attestation by MD, on January 26, 2022 05:30 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions:    none