Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Platelet count decreased, Pneumonia, Protein total normal, Red blood cell count decreased, Red cell distribution width normal
Clinical narrative: Hospitalized (1.4.22 - 1.8.22); COVID-19 positive -reported from home test(12.26.21); Fully vaccinated  pfizer x2 D/c Summary: Discharge Summary (Physician) ? ? General Medicine Expand All Collapse All  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/4/2022 Discharge Date: Jan 8, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Acute respiratory failure due to COVID-19 (HCC) 01/04/2022 Unknown   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Platelets decreased (HCC) 04/30/2021 Unknown ? Other hyperlipidemia 10/06/2020 Unknown ? Bilateral hearing loss 02/11/2019 Unknown ? Cervical spondylosis with myelopathy 01/23/2019 Unknown ? Central cord syndrome at C3 level of cervical spinal cord, initial encounter (HCC) 01/23/2019 Unknown ? Atherosclerotic heart disease of native coronary artery without angina pectoris 03/06/2017 Unknown ? Essential (primary) hypertension 03/06/2017 Unknown ? Status post coronary artery stent placement 03/06/2017 Unknown ? Mitral valve insufficiency, unspecified etiology 03/06/2017 Unknown ? Mixed dyslipidemia 03/06/2017 Unknown ? Statin intolerance 03/06/2017 Unknown ? Transient cerebral ischemic attack, unspecified 03/06/2017 Unknown     Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:  - Follow up Chest X ray in 4-6 weeks - Follow up with COVID at home    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia due to COVID-19 virus [U07.1, J12.82] Acute respiratory failure due to COVID-19 (HCC) [U07.1, J96.00]   HOSPITAL COURSE: Pt is a 75 yr old M with PMHx of CAD, HTN, OSA, Gout presented to ED on 1/4 with multiple symptoms that started on 12/23, including fatigue, weakness, shortness of breath, and poor oral intake. He was found to have hypoxic of 87% on room air.    Upon arrival, patient was hemodynamically stable but required 2L NC. CTA thorax showed no PE, demonstrated bilateral opacities consistent with pneumonia. He was given 500cc normal saline given his history and solumedrol. Admitted for Acute Hypoxic Respiratory Failure due to COVID-19 pneumonia. Upon admission - started on Decadron x 10 days (out of window for Remdesivir).    He had increased needs upto 4L NC at rest, but this was closely monitored and stabilized over 2 days. Repeat Chest X ray showed stability. Patient felt stronger, had a good appetite and denied any concerns. He demonstrated appropriate use of Incentive Spirometer.   Pulmonary Rehab evaluated patient - recommended 4L NC at rest and 6L NC with activity. CM set him up with COVID at home program.   On 1/8 - patient felt well and ready to go home. Denied any new concerns. We discussed COVID precautions, information give on VTE prevention.   He is discharged on 5 additional days of Decadron to complete a total of 10 days and home oxygen. He will need PCP followup within 1 week and repeat Chest X ray in 4-6 weeks to ensure resolution of pneumonia. Wife updated via phone call and agreement with plan.    CONSULTS: None   PROCEDURES: None       CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:   BP 121/65  | Pulse 69  | Temp 36.3 °C (Oral)  | Resp 18  | Ht 1.829 m  | Wt 97.1 kg  | SpO2 94%  | BMI 29.03 kg/m²    Physical Exam Vitals and nursing note reviewed.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Decreased bilateral breath sounds 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 and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal  H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN:     Acute hypoxemic respiratory insufficiency, secondary to COVID-19 pneumonia -CTA thorax: bilateral pneumonia, no PE -vaccinated, latest vaccine dose 2/13/21 -decadron 6mg x 10 days, or until discharge/no longer hypoxemic -outside of remdesivir window, symptom onset 12 days prior to admission -dvt px: SQ lovenox -encourage deep breathing -wean o2 as tolerated   Poor oral intake -likely secondary to viral infection -s/p 500 cc bolus in ED, avoid further IV fluid given hypoxemia -encourage oral repletion, can reassess for IVF tomorrow   Fall -GLF, mechanical, without significant head trauma or LOC -likely worsened by poor oral intake -PT/OT appreciated   CAD Mixed dyslipidemia -stable -ASA -Statin intolerance, can only tolerate fluvastatin which is not on formulary -can bring home med tomorrow if desired   HTN -stable -ARB interchange for home micardis   OSA -not on cpap chronically   Gout -stable -uloric   Diet: salt restrict DVT px: SQ lovenox Code: Full   Observation status discussed with patient and daughter, anticipate <2 midnights but this may change depending on clinical picture             Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 75 y.o. male who presents today with dyspnea. Interviewed in presence of daughter, who is a nurse, with patient's permission. He has been having symptoms since 12/23, including dyspnea, poor oral intake, nausea, no vomiting or diarrhea. The dyspnea has been progressive. His home pulse ox had been steadily dropping to the low 90's, an dropped to 87% today. Daughter mentions intermittent lightheadedness as well as a mechanical fall in bathroom, patient reports there was a wet spot in the bathroom, fell without LOC or head trauma, no incontinence, jerking or confusion reported afterward. Given the patient's hypoxia combined with poor oral intake, they presented to the hospital.   Upon arrival, patient was hemodynamically stable but required 2L NC. CTA thorax showed no PE, demonstrated bilateral opacities consistent with pneumonia. He was given 500cc normal saline given his history and solumedrol. Being brought into hospital for further observation.    Patient Active Problem List Diagnosis ? Atherosclerotic heart disease of native coronary artery without angina pectoris ? Essential (primary) hypertension ? Status post coronary artery stent placement ? Mitral valve insufficiency, unspecified etiology ? Mixed dyslipidemia ? Statin intolerance ? Transient cerebral ischemic attack, unspecified ? Cervical spondylosis with myelopathy ? Central cord syndrome at C3 level of cervical spinal cord, initial encounter (HCC) ? Bilateral hearing loss ? Platelets decreased (HCC) ? Other hyperlipidemia ? Pneumonia due to COVID-19 virus  Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for chills, diaphoresis, fever and unexpected weight change.  HENT: Negative for congestion, rhinorrhea, sneezing and hoarse voice.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing and sputum production.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea, claudication, leg swelling and PND.  Gastrointestinal:  Positive for nausea. Negative for vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for difficulty urinating, dysuria and urgency.  Musculoskeletal:  Negative for joint pain, joint swelling and muscle pain.  Neurological:  Positive for dizziness, light-headedness and weakness (generalized). Negative for headaches.  Psychiatric/Behavioral:  Negative for suicidal ideas, anxiety and hallucinations.  Skin:  Negative for itching.          Objective    OBJECTIVE: BP 155/66  | Pulse 62  | Temp 36.9 °C (Oral)  | Resp 25  | Wt 97.1 kg  | SpO2 95%  | BMI 29.86 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    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 or rales.  Abdominal:     General: There is no distension.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No tenderness (no calf ttp).     Right lower leg: No edema.     Left lower leg: No edema.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Comments: No asymmetric motor weakness, gait unable to assess  Psychiatric:        Mood and Affect: Mood normal.