Age: 85.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory failure, Anion gap, Asthenia
Clinical narrative: Date of Service Sep-20-2022 0819  Chief Complaint Resting comfortably, hungry  HPI / Subjective The patient is an 86-year-old male with history of type 2 diabetes, atrial fibrillation on apixaban, coronary artery disease with CABG, COPD, and gout that presented to the ED last night due to increased weakness and inability to get out of bed for the last day or 2. For the last few days he has gotten progressively weaker. This is hospital day 3.  The patient was examined at bedside and found in no acute distress. He stated he slept approximately 5 hours last night which is adequate for him. He is voiding appropriately although says he's urinating a bit more than usual. His appetite was strong and he looked forward to food after the stress test. He did not report any problems with breathing.  REVIEW OF SYSTEMS General - No fevers, chills, night sweats, or headache.  Eyes - No eye pain, no discharge.  ENT - No sore throat, no nasal congestion.  Respiratory - No pain with breathing. No cough. No increase in shortness of breath above baseline.   Cardio - No chest pain. No palpitations.  Gastrointestinal - No abdominal pain. No nausea or vomiting. No diarrhea or constipation.  Genitourinary - Complains of increased urinary frequency. No dysuria.   Neurologic - No focal weakness. No numbness or tingling.  Objective Vital Signs Sep-20-2022 0709 T     96.5 HR     47 RR 18 BP   142 / 62 O2Sat 97 Sep-20-2022 0400 T     96.7 HR     51 RR 20 BP   141 /     52  O2Sat 93 Intake and Output previous day current day encounter cumulative Intake 1246 ? 3637 Output 1935 180 4765 Diff (I-O) (-689) (-180) (-1128) PHYSICAL EXAM General - Of stated age. Slightly unkempt appearing.   Eyes - Clear with no conjunctival injection.  ENT - No discharge from nares or external auditory meatus. Mucus membranes moist.   Throat - Soft. No masses appreciated. Trachea midline.  Respiratory - Symmetrical rise of chest wall bilaterally. Lungs clear to auscultation with no wheezes, rhonchi, or adventitious sounds.  Cardio - Regular rate, regular rhythm. No murmurs, rubs, or gallops. Radial pulses +2/4 bilaterally. No jugular venous distention.  Gastrointestinal - Soft and non distended. Non tender to palpation. No guarding or rebound.  Neurological - Sensation to light touch in tact in upper and lower extremities.   Musculoskeletal - No obvious joint deformities.   Psychiatric - Mood and affect appropriate to age and situation.  Lab Results Sep-20-2022 0545 Chemistry GLUCOSE  134BUN  42CREAT  1.9MDRD GFR  34NA  136K  4.1CL  102CALCIUM  7.6CO2  25.8OSMO  284.4ANION GP  12.3BUN/CRE  22.1CRP  0.60 Sep-20-2022 0545 Hematology WBC  11.2RBC  3.61HGB  11.3HCT  32.5MCV  90.0MCH  31.3MCHC  34.8RDW  13.7RDWSD  45.1PLT  152MPV  10.9AUTONEU%  83.4AUTOLYM%  11.1AUTOMON%  4.7AUTOEOS%  0.0AUTOBAS%  0.1AUTONEU#  9.3AUTOLYM#  1.2AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.08IG%  0.7 Sep-20-2022 0545 Serology PROCALC  <0.05 Sep-20-2022 0537 Point Of Care GLUSTX  138 Sep-19-2022 2243 Point Of Care GLUSTX  307 Sep-19-2022 2040 Point Of Care GLUSTX  365 Sep-19-2022 1717 Point Of Care GLUSTX  264 Sep-19-2022 1229 Point Of Care GLUSTX  271 Sep-19-2022 1215 Chemistry GLUCOSE  267BUN  38CREAT  2.0MDRD GFR  32NA  137K  4.0CL  99CALCIUM  8.0CO2  29.8OSMO  292.2ANION GP  12.2BUN/CRE  19.0TROPI-HS  54 Active Medications METOPROLOL TARTRATE 25 MG ORALLY DAILY HOLD FOR HR < 60 OR SBP < 100 INSULIN LISPRO 100 UNIT / ML 3 ML Sliding Scale Dose SUBCUT SSACHS REMDESIVIR 100 MG IVPB Q24HI 200 ML/HR SODIUM CHLORIDE 0.9% 100 ML AMIODARONE HCL 200 MG ORALLY BID REGADENOSON INJ 0.4 MG/ 5 ML 0.4 MG IV PUSH ONCALL DIVALPROEX SODIUM DR 500 MG ORALLY NOON DIVALPROEX SODIUM DR 500 MG ORALLY HS CEFepime HCL INJ 2000 MG IV Q24H 200 ML/HR SODIUM CHLORIDE 0.9% MINIBAG+ 100 ML RENAL DOSE APIXABAN 2.5 MG ORALLY BID RENAL DOSE POTASSIUM CHLORIDE ER 10 MEQ ORALLY NOON TAMSULOSIN HCL 0.4 MG ORALLY NOON PANTOPRAZOLE 40 MG ORALLY QDAY-ES Substituted from omeprazole 40 mg capsule,delayed release (e.c.), 1 CAP ORALLY EVERY MORNING ATORVASTATIN CALCIUM 20 MG ORALLY HS FUROSEMIDE 40 MG ORALLY DAILY FUROSEMIDE 40 MG ORALLY NOON DEXAMETHASONE INJ 4 MG/ML 6 MG IV PUSH DAILY MILK OF MAGNESIA 2400 MG/30ML 2400 MG ORALLY Q24HPRN for CONSTIPATION HOLD FOR LOOSE STOOLS ONDANSETRON HCl INJ 4 MG / 2 ML 4 MG IVPUSH Q8HPRN for NAUSEA/VOMITING CALCIUM ANTACID 1000 MG ORALLY Q4HPRN for DYSPEPSIA ACETAMINOPHEN 650 MG ORALLY Q4HPRN for FEVER OR MILD PAIN 1-3 ON PS max 4,000 milligrams acetaminophen per 24 hours Plan ASSESSMENT  - Acute hypoxic respiratory failure secondary to COVID-19  - Sepsis (tachycardia, tachypnea) secondary to COVID-19, present on admission - Acute kidney injury, Cr 2.1, AKIN stage 1, baseline 1.4 in 2001 - COVID-19 pneumonia - Sinus bradycardia, stable, status post cardioversion 9/19/2022 - 1st degree heart block, status post cardioversion 9/19/2022 - Atrial fibrillation with RVR, resolved - Type 2 myocardial infarction, likely secondary to sepsis, AFib with RVR - Coronary artery disease, s/p CABG - Essential hypertension, controlled - Type 2 diabetes mellitus, on metformin, unknown control - Hyperlipidemia, on atorvastatin  Plan:  The patient has improved clinically stating that his weakness has improved. He was saturating at 97-98% on room air. CRP continues to decrease.   He will undergo a stress test this morning as ordered by Dr.   Per Dr. his metoprolol will be decreased to once per day. Amiodarone drip was discontinued and oral 200 mg BID started.   Although the patient still has a low heart rate he shows no signs of deterioration clinically.   Renal function improved slightly. We will continue with aggressive hydration at 200 mL/hr.   His glucose levels look much better today suggesting the change we made to high dose insulin has worked. He will need outpatient management for his diabetes.   We will continue with dexamethasone, remdesivir, and cefepime. Continue to withhold allopurinol, metformin, losartan due to decreased kidney function.   Morning labs: CBC, BMP, CRP, procalcitonin  Electronically signed by RESIDENT DO on Sep-20-2022 1701 I have seen and physically examined the patient on [9-20-2022] and agree with the documentation the resident. I have also discussed my findings and plan of care with the resident. Any changes and additional information are listed below. Electronically signed by MD on Sep-20-2022 1710