Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, COVID-19 pneumonia, Disorientation, Hyperglycaemia, Mental status changes
Clinical narrative: Date of Admission  01/09/2022   Date of Discharge  01/15/2022   Reason for Hospitalization   paramedics state pt was disoriented upon arrival with O2 sat in 80s. pt unsure of the last time he ate or drank. covid + on 1/4 antibodies on 1/7.  Hospital Course   Patient is an 81-year-old male recently diagnosed with COVID on 1/4 at hospital with PMH of Alzheimer's dementia, hypothyroidism, infrarenal AAA, neuroendocrine small bowel tumor s/p resection on Jan 2021, type 2 DM , HTN, HLD, former smoker presented to the ED for altered mentation and increased O2 requirement 2/2 COVID PNA. Work-up negative for cardiac etiology, negative for PE.  pt was started on dexamethasone and remdesivir.  pt prior to presentation to the ED had been vaccinated with booster x3.  hospital course further complicated by hyperglycemia 2/2 dexamethasone use, and pt was started on lantus 25u qhs and insulin sliding scale (about 2-4 u TID AC with carbs coverage).  evaluated by PT and was considered appropriate to go home with close follow up. home O2 eval was performed on 1/15 and was found to require 2L O2 during ambulation.  was deemed stable to be discharged home on 1/15 with 4 days of dexamethasone 6mg PO and home oxygen supply.  Considering pt's advanced age, medicine team decided not to start pt on insulin for steroid use.  will follow up with PCP within 7d post discharge for lab and outpt eval.   Discharge Diagnoses      Pneumonia due to COVID-19 virus    Ordered:   DME - Home Oxygen Discharge     Orders:   dexAMETHAsone, 6 mg = 1 Tablet(s), Oral, Daily, X 4 day(s), # 4 Tablet(s), Refill(s) 0, 01/20/22, Pharmacy: PHARMACY HOSP, bedside delivery, 175, cm, 01/12/22 22:09:00, Height (cm), kg, 01/10/22 14:59:00, Weight (kg), 98.2  Discharge Patient  Other Diagnoses   Ongoing  Alzheimer's disease  AMD (age-related macular degeneration), bilateral  BPH (benign prostatic hyperplasia)  Diabetes  History of colon polyps  History of kidney stones  Hyperlipidemia  Hypertension  Hypothyroid  Intermediate stage dry age-related macular degeneration of both eyes  Macular degeneration, wet  Neuroendocrine carcinoma of small bowel  Obesity  Pseudophakia  Pseudophakia of both eyes  Historical  No qualifying data        Discharge Disposition  Home    Medications  New, Changed, or Refilled Medications  dexAMETHAsone (dexAMETHAs 6 mg, 1 Tablet(s), Oral, Daily, for 4 day(s), 4 Tablet(s), 0 Refill(s)      Medications to be Continued  acetaminophen (Tylenol Ex 1,000 mg, 2 Tablet(s), Oral, tid, 0 Refill(s)    aspirin (aspirin 81 mg or 81 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)    cholecalciferol (cholecal 5,000 IntUnits, 1 capsule(s), Oral, Daily    cyclobenzaprine (cycloben 5 mg, 1 Tablet(s), Oral, tid, 0 Refill(s)    donepezil (donepezil 10 m 10 mg, 1 Tablet(s), Oral, At Bedtime    gabapentin (gabapentin 30 300 mg, 1 capsule(s), Oral, tid, 0 Refill(s)    levothyroxine (levothyrox 100 mcg, 1 Tablet(s), Oral, Daily    losartan (Cozaar 50 mg) 50 mg, 1 Tablet(s), Oral, Daily, 0 Refill(s)    memantine (Namenda 10 mg) 10 mg, 1 Tablet(s), Oral, bid    metFORMIN (metFORMIN 500 500 mg, 1 Tablet(s), Oral, bid    multivitamin with mineral 1 Tablet(s), Oral, Daily    multivitamin with mineral 1 capsule(s), Oral, bid    omeprazole (omeprazole 20 20 mg, 1 capsule(s), Oral, Daily    rosuvastatin (Crestor 10 10 mg, 1 Tablet(s), Oral, At Bedtime, 0 Refill(s)    traMADol (Ultram 50 mg) 50 mg, 1 Tablet(s), Oral, q6h, May take one to two tablets by mouth every six hours, not to exceed six tablets a day., PRN: as needed for pain, 20 Tablet(s), 0 Refill(s)    Instructions:May take one to two tablets by mouth every six hours, not to exceed six tablets a  verapamil (verapamil 180 180 mg, 1 capsule(s), Oral, Daily      Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 36.3 °C  HR: 66  RR: 16  BP: 128/69  SpO2: 95%      Constitutional: No acute distress, resting comfortably in bed Eyes: Sclera/conjunctiva clear; Ears: Normal hearing; Mouth and Throat: Pharynx clear; mucous membranes moist Cardiovascular: Regular rate and rhythm; normal S1 and S2 without murmur or gallop Respiratory: Lungs clear to auscultation, no wheeze, no rales Gastrointestinal: Abdomen soft non-distended without masses or tenderness; BS active Musculoskeletal: Joints without deformity, erythema or warmth; Able to move all 4 extremities against gravity Skin: No rashes or visible lesions Neurologic: Awake and alert; no focal weakness Psychiatric: Normal affect Lymph Nodes: No palpable cervical, supraclavicular or inguinal nodes  Time Spent  45 min spent on clinical care   Follow Up Appointments     Follow Up Appt Clinic Name/Phone: Other - see comments, Provider Name: medical doctor, Within 7 Days, Laboratory Tests, Reason for Exam covid PNA, hyperglyemia, post hosp dc follow up, Comments  Nursing/Other Orders   Diabetic Diet, Adult (carbohydrate consistent). Ordered on 01/10/22 8:00:00, Meal Start Time Breakfast 0700 to 0900   Fall Precautions. 01/10/22 16:21:50. Order comment: order placed from nursing documentation CLIN_FALL_RISK   Activity As Tolerated. 01/09/22 23:48:00, Continuous Order   Code Status. Code Status Description: Full Code     Addendum by medical doctor on January 24, 2022 14:53:06 (Verified)    Attestation by medical doctor on January 24, 2022 14:53 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