Age: 69.0
Sex: M
Vaccine: COVID19-2
Symptoms: Disorientation, Electrocardiogram abnormal, Fibrin D dimer normal, Full blood count normal, Hepatic enzyme increased
Clinical narrative: Discharge Provider: DO Primary Care Provider at Discharge:  DO  Admission Date: 3/13/2023 Discharge Date: 3/14/2023  PRESENTING PROBLEM: Sepsis (HCC) [A41.9]   HOSPITAL COURSE: A 69 y.o. male with past medical history significant for hypertension post-polio syndrome with left lower extremity weakness, atrial fibrillation on Eliquis, obstructive sleep apnea on CPAP, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hyperlipidemia, abdominal aortic aneurysm, gout, arthritis, alpha-1 antitrypsin deficiency, initially presenting to Hospital Emergency Department accompanied by his wife with chief complaint of altered mental status and disorientation.  Symptoms started yesterday.  Patient also reports that he has had a cough for a day or 2.  Patient reports chills. Patient denies any nausea vomiting, no shortness of breath or chest pain, no abdominal pain.  Patient has a history of urinary incontinence and had a Foley catheter placed in the emergency department.  Patient reports chronic left lower extremity weakness secondary to post-polio syndrome.  Patient states that he spends most of his day in a recliner.  Patient is able to ambulate but uses a cane or a walker if he is going outside the house.  Patient denies any numbness or tingling.  No diarrhea constipation.  Patient reports that he is vaccinated for COVID.   In the emergency department, patient was found to be tachycardic and febrile.  Patient was oxygenating 94% on room air.  Patient had no evidence of leukocytosis or pneumonia on chest x-ray, no evidence of urinary tract infection.  Patient tested positive for COVID 19 by PCR.  Patient did have an elevated lactic acid of 2.5 that improved to 1.9 after fluid resuscitation.  Glucose was elevated at 186, patient did have slight bump in liver enzymes with AST of 115 and ALT of 51. EKG with evidence of sinus tachycardia with no acute ischemic process.    In the emergency department, patient as mentioned above was fluid resuscitated with 3 L of normal saline per sepsis protocol.  Patient also received IV antibiotics in the form of IV ceftriaxone and IV azithromycin.    Given patient's altered mental status with evidence of severe sepsis without septic shock, patient was admitted to Hospital for further treatment.   Upon examination after arrival to the medical unit, patient is alert and oriented to person place, time, and situation.  Patient is afebrile, oxygenating 96% on room air, blood pressure within acceptable.  Patient was admitted and monitored.  Sepsis symptoms resolved readily.  Laboratory studies came back mildly elevated CRP normal D-dimer and stable chemistries and complete blood count.  He had no respiratory symptoms.  He was tolerating oral nutrition.  He was able to complete his ADLs without assistance.  He was otherwise stable and deemed ready for discharge.  He was subsequently discharged home to follow-up outpatient with primary care provider.  He was to resume his regular medications as previously ordered.  He could return to his diabetic diet and activity as tolerated.  He understood all these instructions and was discharged home in stable condition.