Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: COVID-19, Cardiac murmur, Condition aggravated, Cough, Dyspnoea
Clinical narrative: Patient is a 82 y.o. male with a past medical history of atrial fibrillation, cardiomyopathy, aortic and mitral valve replacement/repair, pacemaker, squamous cell carcinoma of lung with left-sided lung resection and PVD who presented to emergency department with chief complaint of increasing shortness of breath with nonproductive cough.  He did receive COVID-19 vaccination.  Stated that both he and his wife began feeling ill approximately 1-3 days ago.  He is a difficult historian.  Symptoms are somewhat vague but complained of cough, generalized malaise and possible fever.  Did state that he had a fall onto a carpeted floor due to unknown reason sometime in the last few days.  Reports no injury.   Presented to Emergency Department at approximately 8:00 p.m. on 09/26/2021.  During initial evaluation, he was found in acute kidney injury with a creatinine of 2.0 for, proBNP 1440, initial troponin 49 with repeat 44. Procalcitonin 0.13, lactic acid 2.1 with repeat lactic acid of 1.2.  WBC 7.72.  COVID-19 positive.  Peripheral blood cultures drawn and pending.  UA without evidence of urinary tract infection.  Twelve lead EKG showed ventricularly placed rhythm.   Initially, he was hypotensive and hypoxic.  Received IV fluid bolus in supplemental oxygen.  Blood pressure resolved without additional IV fluid past initial bolus.  Lactic acid improved.  No vasopressor needed.  Hypoxia vastly improved on 2 L via nasal cannula.   On arrival to another Hospital on 09/27/2021, hypoxia had improved.  On room air with saturations 96-97% during examination.  He is very concerned about his spouse, who has mental health issues.  Unsure of patient's mental baseline.  Due to recent fall and questionable status, care management, physical therapy and occupational therapy consultations requested.   Although he was initially treated with COVID-19 pneumonia, dose have left lobe resection history which may have contributed to x-ray findings. Was treated with one dose of remdesivir which was then subsequently discontinued due to vast improvement of pulmonary status.  Dexamethasone was continued.   Throughout hospitalization, pulmonary status remained stable.  Did not require supplemental oxygen.  Was able to work with physical and occupational therapy.  Although they recommended home health, this was declined by family.  Appreciate care management exploration of services although there were declined.   Of note, mental status was questioned.  Patient, on multiple occasions, eluded to the fact that he wanted to die with his wife.  He also alluded to euthanasia.  He was evaluated by social work.  Was not felt to be a danger or suicidal.  Mental status was discussed with family who states that this is his baseline.   Today, he is sitting up in bed no acute distress.  No complaints of pain, difficulty breathing, dizziness, shortness of air.  He is looking for to discharge home.  Phone call was made to daughter to discuss discharge plan which she is agreeable to.   Patient is stable for discharge home to the care of his family at this time.  All questions and concerns were addressed.  Please see discharge instructions for further information.     BP (!) 110/46  | Pulse 63  | Temp 36.6 °C (Oral)  | Resp 22  | Ht 1.854 m  | Wt 106.4 kg  | SpO2 95%  | BMI 30.94 kg/m²       Physical Exam    Physical Exam    Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregular.     Heart sounds: Murmur heard.  No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing, rhonchi or rales.  Abdominal:     General: Bowel sounds are normal. There is distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No swelling, tenderness or deformity. Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not pale.     Findings: No erythema or rash.  Neurological:     Mental Status: He is alert and oriented to person only. Mental status is at baseline per family (has baseline confusion).     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:        Speech: Speech is tangential.        Behavior: Behavior normal.     Comments: Difficult to keep on task during conversation.  Generally a poor historian.    PERTINENT LABS AND STUDIES: All pertinent labs and studies were reviewed prior to discharge.