Age: 60.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Monocyte percentage increased, Neutrophil count normal, Neutrophil percentage increased, Platelet count normal, Prohormone brain natriuretic peptide increased
Clinical narrative: Date of Admission Admit Date: Jan-05-2022 Date of Discharge Date of discharge Jan-09-2022 Allergies Penicillins - Anaphylaxis Niacin - Not Specified diazePAM - Not Specified Chief Complaint weakness and fatigue Procedure(s) Performed None Lab Results Jan-09-2022 0800 Chemistry  LDH 434 (H) Jan-09-2022 0730 Hematology  WBC 6.5 RBC 5.45 HGB 15.2 HCT 45.1 MCV 82.8 MCH 27.9 MCHC 33.7 RDW 15.8 (H) RDWSD 47.1  PLT 228 MPV 10.8 (H) AUTONEU% 77.1 (H) AUTOLYM% 13.6 (L) AUTOMON% 8.5 AUTOEOS% 0.0  AUTOBAS% 0.2 AUTONEU# 5.0 AUTOLYM# 0.9 (L) AUTOMON# 0.6 AUTOBAS# 0.0 AUTOEOS# 0.0  NRBC% 0.0 NRBC 0.0 HGB/HCT 3.0 IG# 0.04 IG% 0.6 Jan-09-2022 0730 Chemistry  GLUCOSE 184 (H) BUN 15 CREAT 0.6 (L) MDRD GFR 137 NA 129 (L) K 4.9 CL 96 (L)  CALCIUM 8.2 (L) CO2 21.5 (L) OSMO 264.5 (L) ANION GP 16.4 BUN/CRE 25.0 (H)  CRP 0.50 (H) Jan-09-2022 0528 Point Of Care  GLUSTX 217 (H) Jan-08-2022 2025 Point Of Care  GLUSTX 267 (H) Jan-08-2022 1634 Point Of Care  GLUSTX 316 (H) Jan-08-2022 1207 Point Of Care  GLUSTX 193 (H) Jan-08-2022 0630 Hematology 1 of8  Jan-09-2022 0925 Attending Encounter  Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service   WBC 4.8 RBC 5.29 HGB 14.8 HCT 43.8 MCV 82.8 MCH 28.0 MCHC 33.8 RDW 15.6 (H) RDWSD 46.6  PLT 187 MPV 10.3 AUTONEU% 77.2 (H) AUTOLYM% 13.8 (L) AUTOMON% 8.6 AUTOEOS% 0.0  AUTOBAS% 0.2 AUTONEU# 3.7 AUTOLYM# 0.7 (L) AUTOMON# 0.4 AUTOBAS# 0.0 AUTOEOS# 0.0  NRBC% 0.0 NRBC 0.0 HGB/HCT 3.0 IG# 0.01 IG% 0.2 Jan-08-2022 0630 Chemistry  GLUCOSE 246 (H) BUN 15 CREAT 0.7 MDRD GFR 115 NA 134 K 4.1 CL 100 CALCIUM 8.2 (L)  ALK PHOS 90 CO2 24.1 AST 21 ALT 32 AST/ALT 0.7 (L) TL PROT 6.2 (L) ALBUMIN 2.4 (L)  TBILI 0.5 DBILI 0.1 OSMO 277.3 ANION GP 14.0 BUN/CRE 21.4 (H) CRP 0.60 (H) Jan-07-2022 0705 Hematology  WBC 5.0 RBC 5.66 HGB 15.7 HCT 47.0 MCV 83.0 MCH 27.7 MCHC 33.4 RDW 15.9 (H) RDWSD 47.6  PLT 197 MPV 10.4 AUTONEU% 79.2 (H) AUTOLYM% 11.5 (L) AUTOMON% 8.7 AUTOEOS% 0.0  AUTOBAS% 0.2 AUTONEU# 4.0 AUTOLYM# 0.6 (L) AUTOMON# 0.4 AUTOBAS# 0.0 AUTOEOS# 0.0  NRBC% 0.0 NRBC 0.0 HGB/HCT 3.0 IG# 0.02 IG% 0.4 Jan-07-2022 0705 Chemistry  GLUCOSE 223 (H) BUN 21 CREAT 0.8 MDRD GFR 99 NA 133 (L) K 4.3 CL 99 CALCIUM 8.6  CO2 24.7 OSMO 276.3 ANION GP 13.6 BUN/CRE 26.3 (H) CRP 1.40 (H) Jan-06-2022 0635 Hematology  WBC 6.2 RBC 6.07 HGB 17.0 HCT 49.9 MCV 82.2 MCH 28.0 MCHC 34.1 RDW 16.7 (H) RDWSD 47.8  PLT 180 MPV 11.0 (H) AUTONEU% 83.4 (H) AUTOLYM% 8.7 (L) AUTOMON% 7.4 AUTOEOS% 0.0  AUTOBAS% 0.2 AUTONEU# 5.2 AUTOLYM# 0.5 (L) AUTOMON# 0.5 AUTOBAS# 0.0 AUTOEOS# 0.0  NRBC% 0.0 NRBC 0.0 IG# 0.02 IG% 0.3 Jan-06-2022 0635 Chemistry  GLUCOSE 245 (H) BUN 23 CREAT 0.8 MDRD GFR 99 NA 133 (L) K 4.5 CL 101 CALCIUM 8.3 (L)  CO2 17.8 (L) OSMO 278.2 ANION GP 18.7 BUN/CRE 28.8 (H) HGBA1C 8.1 MEAN GLU 211 Jan-05-2022 0645 Hematology  WBC 4.1 (L) RBC 6.36 (H) HGB 17.7 HCT 52.6 (H) MCV 82.7 MCH 27.8 MCHC 33.7 RDW 16.9 (H)  RDWSD 47.1 PLT 165 MPV 9.9 AUTONEU% 79.9 (H) AUTOLYM% 10.6 (L) AUTOMON% 9.1 (H)  AUTOEOS% 0.0 AUTOBAS% 0.2 AUTONEU# 3.2 AUTOLYM# 0.4 (L) AUTOMON# 0.4 AUTOBAS# 0.0  AUTOEOS# 0.0 NRBC% 0.0 NRBC 0.0 HGB/HCT 3.0 IG# 0.01 IG% 0.2 Jan-05-2022 0645 Chemistry  GLUCOSE 223 (H) BUN 18 CREAT 0.8 MDRD GFR 99 NA 134 K 4.4 CL 100 CALCIUM 8.3 (L)  ALK PHOS 103 CO2 16.4 (L) AST 27 ALT 24 AST/ALT 1.1 TL PROT 6.5 ALBUMIN 2.7 (L)  TBILI 0.6 DBILI 0.2 OSMO 277.1 ANION GP 22.0 BUN/CRE 22.5 (H) LDH 387 (H)  TROPI <0.017 CRP 15.60 (H) FERRITIN 1484 (H) PROBNP 868 (H) Jan-04-2022 1136 Hematology  WBC 6.0 RBC 6.31 (H) HGB 17.7 HCT 52.9 (H) MCV 83.8 MCH 28.1 MCHC 33.5 RDW 17.0 (H)  RDWSD 48.6 PLT 184 MPV 10.8 (H) AUTONEU% 79.9 (H) AUTOLYM% 10.2 (L) AUTOMON% 9.5 (H)  AUTOEOS% 0.0 AUTOBAS% 0.2 AUTONEU# 4.8 AUTOLYM# 0.6 (L) AUTOMON# 0.6 AUTOBAS# 0.0  AUTOEOS# 0.0 NRBC% 0.0 NRBC 0.0 HGB/HCT 3.0 IG# 0.01 IG% 0.2 Jan-04-2022 1136 Chemistry 2 of8  Jan-09-2022 0925 Attending Encounter  Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service   GLUCOSE 183 (H) BUN 19 CREAT 1.0 MDRD GFR 76 NA 129 (L) K 4.7 CL 95 (L) CALCIUM 8.6  ALK PHOS 108 CO2 17.2 (L) AST 29 ALT 27 AST/ALT 1.1 TL PROT 7.6 ALBUMIN 2.8 (L)  TBILI 0.6 OSMO 265.9 (L) ANION GP 21.5 BUN/CRE 19.0 TROPI <0.017 CRP 14.20 (H)  LACTATE 2.70 (H) PROBNP 1206 (H) Imaging Results 01/04/2022: Echocardiogram per official report Including left ventricular ejection fracture greater than 60% Mild left ventricular hypertrophy Mild left atrial enlargement which is consistent with Elie index line between 35-41 cm Aortic cusp mildly calcified Mild mitral annular calcification Small pericardial effusion 01/04/2022 CXR of the chest per official report Findings Frontal portable chest radiograph. Patchy bilateral interstitial and airspace opacities likely multifocal pneumonia in the acute setting. COVID is consideration. No pleural effusion or pneumothorax. The cardiac silhouette is enlarged. The mediastinal silhouette is normal . The visible bony thorax is acutely intact. Impression Patchy bilateral interstitial and airspace opacities likely multifocal pneumonia in the acute setting. Covid is a consideration 01/04/2022 CTA per official report    Findings There are no filling defects in the pulmonary arteries to suggest pulmonary embolism. The aorta and coronary arteries are normal in course and caliber. The coronary arteries and aorta are atherosclerotic. Moderate patchy ground-glass opacities and interstitial thickening noted bilaterally, compatible with COVID pneumonia. Trace left pleural thickening/pleural effusion. There is no evidence of pneumothorax. The trachea is patent and midline The heart size is mildly enlarged. No pericardial effusion is present. Prominent hilar and mediastinal nodes are likely reactive. The liver is hypoattenuating compatible with steatosis. Bone windows demonstrate no suspicious lytic or blastic lesions. The visible osseous structures are intact. Follow flowing ventral osteophytes in the thoracic spine compatible with diffuse idiopathic skeletal hyper no stenosis. Impression 1.) No evidence of pulmonary embolism 2.) Moderate patchy ground-glass opacities and interstitial thickening noted bilaterally, compatible with COVID pneumonia. 1/5/2022 Chest x-ray one view per official report   Findings Unchanged cardiomediastinal silhouette. Diffuse bilateral interstitial thickening and patchy bilateral airspace opacities with interval worsening. Note definite pleural effusions or pneumothorax. 3 of8  Jan-09-2022 0925 Attending Encounter  Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service  Impression Worsening bilateral interstitial and airspace disease favoring COVID 19 pneumonia 1/5/22 Transeophageal echocardiogram with cardioversion report per official report  Findings Left Ventricle: Normal left ventricular systolic function. No left ventricular thrombus visualized. Left Atrium: No left atrial thrombus. Mitral Valve: Trivial mitral regurgitation. Aortic Valve: Aortic cusps appear mildly calcified. Trace aortic valve regurgitation. Pericardium: Small pericardial effusion. No echocardiographic evidence to suggest pericardial tamponade. Conclusions Normal left ventricular systolic function. No left ventricular thrombus visualized. No left atrial thrombus. Trivial mitral regurgitation. Aortic cusps appear mildly calcified. Trace aortic valve regurgitation. Small pericardial effusion. No echocardiographic evidence to suggest pericardial tamponade. No evidence for left or right atrial appendage thrombus. Functional Status* Impaired mobility Mental Status* Normal Cognition Social History tobacco use  Former Smoker  Quit approximately 10/2021. 15 pack-year history. alcohol use  Beer drug use  No Known Use marital status  Divorced occupation  Former forklift operator general comment  Lives in apartment by himself. Health Concerns Pneumonia caused by SARS-CoV-2 Acute hypoxemic respiratory failure COVID-19 Re-entrant atrioventricular node tachycardia Coronary arteriosclerosis in native artery History of placement of stent for coronary artery disease Essential hypertension 4 of8  Jan-09-2022 0925 Attending Encounter  Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service  Peripheral arterial occlusive disease Diabetes mellitus Chronic obstructive lung disease Hyperlipidemia History of cerebrovascular accident without residual deficits Amputation above-knee Atrial fibrillation with rapid ventricular response Former Smoker Beer Mother Deceased Myocardial infarction @ 41 Vital Signs Jan-09-2022 0700  T 97.8 HR 62 RR 20 BP 157 (H) / 95 O2Sat 93 Jan-09-2022 0400  T 97.5 HR 54 (L) RR 22 (H) BP 142 / 80 O2Sat 90 Physical Exam General Normal appearance, Awake, Alert Respiratory Lung sounds normal, Symmetry of chest movement Negative For: Shortness of breath, Tachypnea, Decreased breath sounds Cardiovascular Cardiovascular System Normal, Heart Rhythm Regular, Regular Rate Peripheral Vascular/Extremities Peripheral pulse palpable, No Swelling Abdomen Abdomen soft, Flat, Bowel sounds normal Skin/Integumentary Skin Appearance Skin appearance normal, Dry skin, Moist Mucous Membranes Negative For: Nonpitting edema, Pitting edema Neurological Normal neurological function, Normal cranial nerves 2-12, Follows commands Consultations Cardiologist Hospital Course 01/5/22: Patient admitted under care of IM team for acute respiratory failure secondary to COVID pnuemonia and atrial fibrillation with RVR. Cardiologist was consulted. Patient was continued on oxygen supplementation Nasal canula. Cardizem drip was dicontinued.  Amiodarone was continued. Dexamethasone was started.  Home diabetic medications were held. Sliding insulin scale was started. CXR, echo and CTA were ordered. Cardioversion was attempted but was not successful. Physical therapy ordered started.  1/6/22: Patient had been titrating down to 6 liters of oxygen but went back up to 12 liters of oxygen HF NC.  Foley catheter was removed. Patient returned into sinus rhythm. Cardiology reviewed patient. Patient continued on current hospital medication regimen.  Lidocaine ointment was given for skin lesion on his buttocks. 5 of8  Jan-09-2022 0925 Attending Encounter  Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service  1/7/2022: Patient titrated down to 5 liters oxygen nasal cannula retaining oxygen saturation above 88%.  Lidocaine ointment has provided relief.  Physical therapy continued.   1/8/2022: Patient was back up to 12 liters of oxygen via HF NC overnight but titrating down to 6 throughout the day retaining oxygen saturation above 88%. Patient given dexamethasone and remdisivir treatment.  Physical therapy was continued.  Patient did complain of left ear pain that had been mild and intermittent the last few days before worsening. Patient was treated with an ear currete, ear lavage and given ear drops.   1/9/2022 Patient discharged back to home, clinically and hemodynamically stable.  Reports his left ear feels better. No other complaints or concerns at this time. Condition at Discharge Stable Discharge Medications ACETAMINOPHEN 650 MG ORALLY EVERY 4 HOURS AS NEEDED for FEVER OR MILD PAIN 1-3 ON PS AMIODARONE HCL 200 MG ORALLY TWICE DAILY  amLODIPine Besylate Oral Tablet 10 MG 10 MG ORALLY ONCE A DAY Ammonium Lactate External Lotion 12 % 1 APP TOPICAL TWICE DAILY Cetirizine HCl Oral Tablet 10 MG 10 MG ORALLY ONCE A DAY Clopidogrel Bisulfate Oral Tablet 75 MG 75 MG ORALLY ONCE A DAY Dexamethasone Oral Tablet 6 MG 6 MG ORALLY ONCE A DAY  Eliquis Oral Tablet 5 MG 5 MG ORALLY TWICE DAILY Fluticasone Propionate Nasal Suspension 50 MCG/ACT 1 SPR NASAL ONCE A DAY Gabapentin Oral Capsule 300 MG 900 MG ORALLY EVERY MORNING Gabapentin Oral Tablet 600 MG 1200 MG ORALLY EVERY EVENING Isosorbide Mononitrate Oral Tablet 20 MG 20 MG ORALLY TWICE DAILY Jardiance Oral Tablet 25 MG 25 MG ORALLY ONCE A DAY Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML 15 UNT SUBCUTANEOUSLY ONCE A DAY Metoprolol Tartrate Oral Tablet 50 MG 50 MG ORALLY TWICE DAILY Multivitamin Adult Oral Tablet 1 TAB ORALLY ONCE A DAY NEOMYCIN-POLYMYXIN-HC OTIC 10 ML 4 GTT OTIC 4 TIMES A DAY  6 of8  Jan-09-2022 0925 Attending Encounter Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service  Nitroglycerin Sublingual Tablet Sublingual 0.4 MG 0.4 MG SUBLINGUAL AS NEEDED PER INDICATION for OTHER (SEE COMMENTS) Pataday Ophthalmic Solution 0.2 % 1 DRP BOTH EYES ONCE A DAY Quinapril HCl Oral Tablet 5 MG 5 MG ORALLY ONCE A DAY Rosuvastatin Calcium Oral Tablet 40 MG 40 MG ORALLY EVERY EVENING Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT 2 PUF INHALATION ONCE A DAY Trintellix Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY Trulicity Subcutaneous Solution Pen-injector 3 MG/0.5ML 3 MG SUBCUTANEOUSLY EVERY WEEK Vascepa Oral Capsule 1 GM 2 GM ORALLY TWICE DAILY Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 PUF INHALATION EVERY 4 HOURS Discharge Disposition Discharge to home Spoke with case management. He will be discharging back home. He doesn't want to go to a skilled nursing facility. No home health is available where he resides. Plan Assessment: -Acute hypoxemic respiratory failure secondary to COVID-19 pneumonia, , improving currently requiring 3 liters of oxygen -COVID-19 pneumonia -Atrial fibrillation with rapid ventricular response, currently sinus rhythm on oral amiodarone -Anion gap metabolic acidosis likely secondary to starvation ketoacidosis, resolved 01/08/2022 -Hyponatremia, 134 improving -Essential hypertension -Diabetes mellitus type II, unknown control, with nephropathy -History of myocardial infarction x 3 with stent placement x 6, ca. 2016-2021 -History of CVA x 3, ca. 2009-2017 -History of DVT, per patient history -Chronic obstructive pulmonary disease -Peripheral vascular disease -Hyperlipidemia -Obesity -Left above the knee leg amputation Plan: Patient will be discharged to home. Home meds will be restarted. Patient will need to be discharged on supplemental oxygen. Continue dexamethasone 6 mg po QD until completion of therapy. Continue neomycin/polymyxin/hydrocortisone ear drop until completion of therapy. Recommendation to follow up with his PCP within one week. Follow up appointment with cardiologist within 1-2 weeks. Discharge Instructions Diet Diabetic diet 7 of8  Jan-09-2022 0925 Attending Encounter  Discharge Summary  Admitted Discharged Jan-05-2022 Jan-09-2022 Date of Service  Activity as tolerated  Electronically signed on Jan-09-2022 1044