Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Atrial enlargement, Blood bicarbonate increased, Blood chloride normal, Blood creatinine increased, Blood glucose normal
Clinical narrative: Hospitalized (1.11.22 - still admitted currently); COVID-19 positive (1.11.22); Fully vaccinated - pfizer x2 H&P: Admission History and Physical    CHIEF COMPLAINT cough   ASSESSMENT AND PLAN Covid-19 - patient with symptoms starting Sunday and positive PCR 1/11. Vaccinated but not boosted - currently stable on RA but family reports desaturations into 80s at home - CXR showing L basilar opacity, atelectasis vs inflammatory  - not currently a candidate for steriods/remdesivir as stable on RA - prn supportive care - continue to monitor pulse ox   Acute Kidney Injury - Likely secondary to dehydration - Cr 1.89, baseline 0.8-9 - given 500 ml NS bolus in ED, will give gentile IVF for a few hours - avoid nephrotoxins and renally dose medications - consider renal ultrasound and nephrology consult if no improvement - monitor renal function with BMP   Essential HTN - holding home olmesartan-HCTZ with AKI - continue home Norvasc   HDL - continue home statin and ASA   Vascular dementia - daughter is DPOA and currently resides with his Son - baseline  A&O 1-2 - continue home Razadyne    Diet: heart healthy  VTE Prophylaxis: low risk per VTE assessment, early and progressive ambulation   Code status: Full Code per daughter who is DPOA   Above assessment and plan discussed with Dr. whose insight is reflected above.   HISTORY OF PRESENT ILLNESS Patient is a 84 y.o. male with past medical history significant for vascular dementia, hypertension, hyperlipidemia who presents to the emergency department with complains of cough and hypoxia at home.  Of note, patient was at the urgent care and had a visit to the emergency department earlier this morning.  During those visits, CXR was performed showing left basilar opacity, atelectasis versus inflammatory.  He was stable on room air during those visits so he was discharged home with a home pulse oximeter.  Family returned to the emergency department with reported oxygen saturations in the low 80s at home.  Patient was seen and examined in the emergency department with daughter at bedside.  Per daughter, patient started having covid symptoms on Sunday.  Patient states that he currently feels ?great?.  Patient does have a productive cough.  He denies any shortness of breath.  He does have some minor nasal congestion and his daughter notes he has been complaining of an intermittent sore throat.  Patient denies any fevers, chills, chest pain, abdominal pain, nausea/vomiting, urinary symptoms.  Notes that his last bowel movement was earlier today.  Daughter does report slightly decreased oral intake.  Patient does not use anything for assistance with ambulation at baseline.  Per daughter, baseline mentation is A&O 1-2 and he is at his baseline currently.   Upon arrival to the ED, patient vitals were stable. Baseline blood work was obtained showing AKI but otherwise unremarkable. Covid PCR was positive earlier in the day. CXR was not repeated as it was performed earlier today. Patient was saturating well on room air. He was given 500 ml bolus and then admitted to general medicine under observation for further evaluation and management.    Patient Active Problem List Diagnosis ? HTN (hypertension), benign ? Mixed hyperlipidemia ? Intermediate stage nonexudative age-related macular degeneration of both eyes ? Posterior vitreous detachment of right eye ? Exudative age-related macular degeneration of right eye with active choroidal neovascularization (HCC) ? Alzheimer's disease, unspecified (HCC) ? Essential hypertension ? Vascular dementia without behavioral disturbance (HCC) ? COVID-19  REVIEW OF SYSTEMS Review of Systems  Unable to perform ROS: Dementia  Constitutional: Positive for appetite change and fatigue. Negative for chills and fever.  HENT: Positive for congestion and sore throat.   Respiratory: Positive for cough. Negative for shortness of breath.   Cardiovascular: Negative for chest pain and leg swelling.  Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.  Genitourinary: Negative for difficulty urinating and dysuria.  Musculoskeletal: Negative for arthralgias and gait problem.  Skin: Negative for rash and wound.  Neurological: Negative for headaches.  Psychiatric/Behavioral: Negative for confusion.      OBJECTIVE BP 142/56  | Pulse 73  | Temp 98.2 °F (36.8 °C) (Oral)  | Resp 20  | SpO2 94%  Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Course breath sounds bilaterally with congested, productive cough Abdominal:     General: Bowel sounds are normal. 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 and dry.  Neurological:     Mental Status: He is alert. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.     Comments: Patient A&O 1-2. Very pleasantly demented  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.   1/17/22 - Progress note:  Date of Admission: Hospital Day: 7   Brief Summary 84yo M admitted w/ acute respiratory failure with hypoxia 2/2 COVID19 PNA.  Also with AKI which is now resolved.  Continue steroids.  Hypoxia severe, patient made DNR.    Chief complaint COVID-19   Assessment and Plan Covid-19 Acute respiratory failure with hypoxia  -patient requiring HFNC @ 80% FIO2 and 50L/min from 5L NC yesterday - patient with symptoms starting Sunday and positive PCR 1/11 -Vaccinated but not boosted -CT 1/16 w/o PE and consistent w/ COVID19 PNA   Plan: -solumedrol BID given rapid worsening of hypoxia  -daughter doesn't wish us to start remdesivir  -titrate O2 as able -Sq lovenox  -prone as able  -trial with IV lasix x1 today  -DNR per goals of care w/ patient and family    Acute Kidney Injury - resolved  - Likely secondary to dehydration - Cr 1.89-> baseline post fluids   Plan: -trend  - avoid nephrotoxins and renally dose medications   Essential HTN - holding home olmesartan-HCTZ with AKI (resoled) and well controlled BP off  - continue home Norvasc   HDL - continue home statin and ASA   Vascular dementia - daughter is DPOA and currently resides with his Son - baseline  A&O 1-2 - continue home Razadyne      DVT prophylaxis: SQ  heparin Discussion with family:  Updated daughter/DPOA at bedside  Disposition:  Given dementia and worsening hypoxia hold DC today and plan for tomorrow if stable   Greater than 35 minutes of time was spent on this encounter with more than 50% being used for counseling or care coordination including: Seeing/assessing patient at bedside lengthy discussion w/ daughter on treatment plan, imaging review, coordinating w/ RN    Subjective Patient seen and Examined.  Patient with mild FIO2 increase today, discussed this with him and daughter at bedside at length.  Again reviewed treatment plan.  Discussed CT findings.  Patient himself feels well, denies dyspnea, and only reports cough.  He remains in good spirits.  Discussed how many patients with this high of an O2 need to do improve but some do worsen.   Review of Systems Review of Systems  Constitutional: Negative for chills and fever.  Respiratory: Positive for shortness of breath. Negative for cough, chest tightness and wheezing.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.           Physical Exam BP 118/62  | Pulse 78  | Temp 36.8 °C (Oral)  | Resp 20  | Ht 1.803 m  | Wt 84.3 kg  | SpO2 91%  | BMI 25.91 kg/m²    Intake/Output Summary (Last 24 hours) at 1/17/2022 1538 Last data filed at 1/17/2022 1333 Gross per 24 hour Intake 730 ml Output 1050 ml Net -320 ml   Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     General: No scleral icterus. Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no rebound.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert. Mental status is at baseline. He is disoriented.     Comments: A&O only to self