Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Mental status changes, Metabolic function test normal, Myalgia, Nausea, PCO2 normal
Clinical narrative: Hospitalized (11.14.21 - still admitted);  COVID-19 positive (11.14.21);  fully vaccinated. Chief complaint - COVID-19 HISTORY OF PRESENT ILLNESS: Patient is a 75 y.o. female with history of cardiomyopathy, hypertension, IBS, fibromyalgia, GERD, osteoarthritis, CVA and PMR who presents today with gradual weakness over the last 6 months, acutely worse in the last week with 2 days of upper respiratory symptoms.  Patient states that since being diagnosed with PMR and June of 2021 she has had steadily increasing weakness and no significant improvement in her pain since starting the prednisone.  She has been engaged in a long and slow taper over this time.  Over the last week patient had increasing pain in her back and generalized muscle aches alongside increasing fatigue and weakness.  Two days ago she started to develop upper respiratory symptoms with rhinorrhea, congestion, dry cough and fever.  Patient has chronic nausea that is unchanged along with alternating diarrhea and constipation that is also unchanged.  On the day of admission patient was feeling weak, she stated that she was sitting in her chair watching television and when she went to stand up she had an episode of incontinence which was unusual for her.  She got herself cleaned up and then when she sat back down had another episode of incontinence.  Patient was feeling off and she contacted her daughter as well as the "gentleman who lives upstairs" and they advised that she go to the emergency department to get evaluated.  Patient initially declined but was having worsening pain in her back muscles and was feeling febrile  and weak so in for evaluation. Emergency department course:  On presentation to the emergency department patient was febrile at 38.9° C, pulse 101, respiratory rate 28 and blood pressure 159/89.  Heart rate remained elevated between 101 and 110. Laboratory workup performed, CMP unremarkable, magnesium 1.9, phosphorus 3.1, troponin was not elevated at 12, procalcitonin 0.06.  Urinalysis was negative for infection with only trace leukocyte esterase.  COVID-19 PCR was positive.  Venous blood gas showed pH of 7.4 and pCO2 of 41.7.  Patient's lactic acid is mildly elevated 2.1.  Complete blood count showed hemoglobin 11.4 and WBC count of 8.38.  Chest x-ray showed no evidence of pneumonia.  Peripheral blood cultures were obtained and patient was given a 1 L saline bolus and 1 g of Tylenol.  Patient was noted to be weak and required assistance from nursing to get up to the bedside commode.  Patient's husband did not feel that she was safe to return home with her weakness.  Patient will be admitted for observation, PT and OT. ASSESSMENT / PLAN: COVID-19 pneumonia Generalized weakness Patient has had 2-3 days of upper respiratory symptoms and worsening weakness.  She has had generalized weakness steadily worsening over the past 6 months. Patient is not hypoxic and symptoms have been present for less than 10 days, she does not qualify for remdesivir or Decadron. Main Reason for admission is weakness, patient and a live-in companion did not feel comfortable with discharge home due to level of assistance needed. Date of symptom onset: 11/13 Date of positive test: 11/15 - does not qualify for Decadron or remdesivir treatment at this time - daily CRP, D-dimer, complete blood count and CMP - PT and OT evaluation tomorrow - Tylenol p.r.n. for fever - Mucinex 2 times a day - Motrin 400 mg now for muscle aches Brief history and medical decision making: Patient is a 75-year-old woman with multiple comorbidities and deconditioning who presented to the hospital for shortness of breath and was found to be positive for COVID 19 pneumonia.  She had an episode this morning where she took her high-flow nasal cannula off, became very hypoxic and confused due to the hypoxia and pulled out her IVs. Patient frequently removes her high-flow nasal cannula and forgets that it needs to be kept time.  She ended up needing 100% FiO2 and was saturating in the 80s.  I had a discussion with her and her 2 daughters about code status.  The decision was made to make her do not resuscitate/DNI.  Patient is starting to do better on high-flow nasal cannula at this time.  I also updated her significant other about this decision and he agrees that it would be best that she not be intubated.  Patient's significant other said that he feels like he has COVID in losses sense of taste and smell.  I told him that he should go get tested for COVID and that he should not be in the hospital if he is symptomatic or test positive.  Pt didn't not get any oral meds because of mental status, Pt states that she needs help, but when staff tries to help she gets more agitated. Pulling at oxygen and all tubing safety attendant and nurse has been in there most of the morning. Morphine and ativan given this morning and this seemed to help Pt relax, more ativan was given about two hours later because of agitation. Pt oxygen continues to fluctuate, Pt is on high flow and non rebreather, Provider is aware. Family in this morning