Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Anal incontinence, Aspartate aminotransferase increased, Asthenia, Back pain, Blood alkaline phosphatase increased
Clinical narrative: Hospitalized (1.28.22 - 1.31.22 - RE-ADMITTED 2.5.22 - still inpt with neck pain & AMS); COVID-19 positive (1.28.22); Fully vaccinated  1/28/22 H&P:  CHIEF COMPLAINT Nausea    ASSESSMENT AND PLAN Covid pneumonia - patient presenting with complaints of fever, nausea, vomiting, diarrhea and increased confusion which started yesterday.  Also having minor dry cough. She is vaccinated but not boosted.   - currently stable on RA - CXR showing findings consistent with Covid pneumonitis - not currently a candidate for interventions as stable on RA              - consider starting Dexamethasone is becomes hypoxic - prn supportive care - monitor on pulse ox  Lactic acidosis, resolved - likely 2/2 dehydration, vomiting and diarrhea - LA 2.3 -> 1.2, WBC WBL - given 2L NS bolus - given Vanc, cefepime, flagyl for empiric sepsis tx in ED, holding off on further Abx - CT A/P negative for acute process - UA negative - stool studies pending - blood cultures pending   AKI on CKD 3 - Cr 2.36, baseline around 1.9 - given 2L NS in ED, will continue with gentile IVF for a few more hours - holding Lasix - avoid nephrotoxins and renally dose medications - continue to monitor  Hypophosphatemia - phos 1.9 - given 15 mmol Kphos - continue to monitor and replace as needed  Chronic HFpEF, stable Essenital HTN - most recent echo showing EF 58% - holding home Lasix with AKI - continue home Norvasc and metoprolol - daily weights, strict I/Os  NIDDM - A1c pending - not currently on medications at home - will place on 24 hour coreective for now - continue to monitor and adjust as needed  HDL CVA - continue home statin  GERD - PPI  Chronic anemia - hgb 10.8 which is baseline  Rheumatoid arthritis Chronic immunosuppression - continue home 5mg Prednisone daily  Vascular Dementia Depression - slightly more altered than normal per daughter at bedside but was started on Tramadol yesterday by PCP for chronic back pain. Daughter would like assistance with official DPOA designation - will stop tramadol - continue home Remeron   Diet:  DM liberal  VTE Prophylaxis:  Lovenox Code status: Full Code per daughter at bedside HISTORY OF PRESENT ILLNESS Patient is a 85 y.o. female with past medical history significant for CVA, vascular dementia, CHF diabetes, depression, hypertension presented to the emergency department complaints of fever, nausea/vomiting and diarrhea.  With patient's dementia, most of history is obtained through daughter a who is at bedside.  Per daughter, patient began having symptoms of fever/chills, nausea/vomiting and diarrhea beginning yesterday 1/27.  Notes that she has been having decreased appetite.  Patient has been complaining intermittently of abdominal pain but denies any pain on admission.  Daughter notes that she does have a minor dry the last few days.  She also notes increased confusion over the last few days with acute worsening yesterday.  Of note, patient did go see PCP yesterday and was started on tramadol for chronic back pain.  Confusion worsened after starting this medication.  Daughter notes that she currently lives with patient.  Patient is ambulatory but uses walker/cane to get around.  Denies any recent falls.  Notes compliance with her medications.  Believes that her sister may have been COVID positive but was never tested.  Patient is vaccinated but not boosted.   Upon arrival to emergency department, patient was febrile, tachycardic.  She was stable on room air.  Baseline blood work was obtained which was remarkable for AKI, hypophosphatemia lactic acid 2.1 and stable chronic anemia.  Sepsis workup was initiated and blood cultures were obtained.  He was negative for acute infection.  COVID PCR was positive.  CXR was obtained consistent with bilateral COVID pneumonitis.  CT abdomen and pelvis was obtained which was negative for acute process.  Patient was empirically started on vanc, cefepime and Flagyl for suspected intra-abdominal infection.  She was also given a 2 L NS bolus.  Repeat lactic acid normalized.  Patient was then transferred to Hospital and admitted to General Medicine for further evaluation and management.   Patient Active Problem List Diagnosis ? Abnormal CT of the abdomen ? Acute kidney injury  ? Alcohol abuse ? Anorexia ? Bilateral cataracts ? Cerebrovascular accident  ? Chronic combined systolic and diastolic heart failure  ? Coronary arteriosclerosis ? Dehydration ? Dementia with behavioral disturbance  ? Diabetic nephropathy  ? Dyslipidemia ? Elevated lipase ? Epigastric abdominal pain ? Hypertension ? General weakness ? Gout ? Non-ST elevation (NSTEMI) myocardial infarction  ? Type 2 diabetes mellitus  ? Community acquired pneumonia, bilateral ? Intractable back pain ? Physical deconditioning ? Protein-calorie malnutrition, moderate  ? COVID-19 Review of Systems  Unable to perform ROS: Dementia  Constitutional: Positive for appetite change, chills and fever.  HENT: Negative for congestion and trouble swallowing.   Respiratory: Positive for cough. Negative for shortness of breath.   Gastrointestinal: Positive for abdominal pain, diarrhea, nausea and vomiting. Negative for abdominal distention.  Neurological: Positive for weakness.  Psychiatric/Behavioral: Positive for confusion.  BJECTIVE BP 136/55  | Pulse 91  | Temp 98.8 °F (37.1 °C) (Oral)  | Resp 25  | Wt 66 kg (145 lb 8.1 oz)  | SpO2 94%  | BMI 28.42 kg/m²  Physical Exam Constitutional:     General: She is not in acute distress. HENT:    Head: Normocephalic and atraumatic.     Mouth/Throat:    Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:    Extraocular Movements: Extraocular movements intact.     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: Normal breath sounds. No wheezing.  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: She is alert. Mental status is at baseline.     Comments: A&O 1-2   Psychiatric:       Mood and Affect: Mood normal.        Behavior: Behavior normal Discharge Summary MD (Physician) ? ? General Medicine  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/28/2022 Discharge Date: Jan 31, 2022 Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? AKI (acute kidney injury)  01/29/2022 02/02/2022 Unknown ? Encephalopathy Sepsis due to COVID pneumonia with possible secondary bacterial infection 01/29/2022 02/02/2022 Yes ? Acute kidney injury     Discharge Disposition:  home health care svc    Active Issues Requiring Follow-up: COVID pneumonia with secondary bacterial infection - follow-up with primary care Dementia - follow-up with primary care, recommend formal neurocognitive evaluation, family to work on guardianship Type 2 diabetes with hyperglycemia - follow-up with primary care DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Severe sepsis [A41.9, R65.20] COVID-19 virus infection [U07.1] COVID-19 [U07.1] AKI (acute kidney injury) N17.9]   HOSPITAL COURSE: 85 y.o. female with past medical history significant for CVA, vascular dementia, CHF diabetes, depression, hypertension presented to the emergency department complaints of fever, nausea/vomiting and diarrhea.    Upon arrival to emergency department, patient was febrile, tachycardic.  She was stable on room air.  Baseline blood work was obtained which was remarkable for AKI, hypophosphatemia lactic acid 2.1 and stable chronic anemia.  Sepsis workup was initiated and blood cultures were obtained.  He was negative for acute infection.  COVID PCR was positive.  CXR was obtained consistent with bilateral COVID pneumonitis.  CT abdomen and pelvis was obtained which was negative for acute process.  Patient was empirically started on vanc, cefepime and Flagyl for suspected intra-abdominal infection.  She was also given a 2 L NS bolus.  Repeat lactic acid normalized.  Patient was then transferred to Hospital and admitted to General Medicine for further evaluation and management.   Patient stayed in hospital for 3 days.  Patient were monitored for her COVID pneumonia and has not needed any oxygen support.  She did not have any fever episodes.  After 1st 24 hours of stay patient has been tolerating diet.  During her monitoring, she had a saturation of 90% but continues to be at room air, she was given a dose of dexamethasone 6 mg once.  The following day, she did pretty well maintaining saturations around 97 to 99% on room air.  Had hyperglycemia that she was given corrective doses of insulin and Decadron discontinued.  Patient remained to be at her baseline mentation and had been engaging to care team.  Her CRP was also monitored and showed down trending.  D-dimers were elevated but were stable.  Lovenox prophylaxis had been given throughout stay.  She was started on antibiotics for possible secondary bacterial infection with Rocephin and doxycycline.  Patient's renal function was also monitored and her AKI had resolved.  Her electrolyte imbalances were corrected.  Her hyperglycemia episode had improved and had shown stability.  PTOT evaluation were completed and recommended home health care with assist provided that caregivers are there 24/7.  This was ensured by family, patient was then discharged home stable.   During stay, attempted completion of DPOA, but patient incapacitated to do this.  Family then informed on accomplishing guardianship after this hospitalization.  Was informed of daughter that they are already in process of doing this. INPATIENT PROCEDURES: BP 128/64  | Pulse 78  | Temp 37.1 °C (Oral)  | Resp 16  | Wt 63.8 kg  | SpO2 98%  | BMI 27.47 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:  General: She is not in acute distress.    Appearance: She is well-developed.  HENT:  Head: Normocephalic and atraumatic.  Eyes:   Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. Pulmonary:  Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal: Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:  Cervical back: Neck supple.  Skin:   General: Skin is warm and dry.  Neurological: Mental Status: She is alert.     Comments: Oriented only to self  Psychiatric:       Cognition and Memory: Cognition is impaired  2/5/22 H&P:CHIEF COMPLAINT: Neck pain, AMS ASSESSMENT / PLAN: COVID 19 -COVID 19 PCR positive: 1/28/2022 (consider clearing from severe respiratory precautions 2/7 pending clinical course) -vaccinated, but not boosted -on RA -CXR with bilateral infiltrates that are stable compared to recent hosptialization -supportive care -tylenol PRN for fever -repeat labs in am   SIRS -ongoing fevers, tachycardia, WBC 12.51 -suspect secondary to above, CXR stable -procal/LA WNL -UA unremarkable -blood Cx pending -possibly secondary to above (unclear onset of symptoms) -no worsening respiratory symptoms per family -follow labs -completed course of doxycycline outpatient    Acute Hyperkalemia -K=5.6 on admission -cardiac monitoring -will start Lokelma -repeat labs in am   Generalized Weakness -PT/OT -nutrition consult  Neck Pain -CT C spine negative -lidoderm patch -Tylenol PRN  Vascular Dementia Depression -continue home meds, med rec pending -increased confusion noted at home per family, oriented to self on admission -will need care management input regarding dispo planning, family reported to ED they can no longer care for patient at home  Chronic Anemia -check Fe studies -Hgb at baseline  Chronic Diastolic HF -echo 11/23: EF=58%, LA mildly dilated -hold LAix, suspect patient dry  CKD Stage III, stable -baseline around 1.2 -follow daily labs -avoid nephrotoxins, renally dose medications  DM Type II, non-insulin dependent -HgbA1c=7.1 -24 hour corrective insulin   HTN -continue home meds  CVA HLD -continue statin  RA Chronic immunosuppression -continue 5mg Prednisone daily  GERD -PPI  DVT PPX: Lovenox SubQ FULL CODE, discussed with daughter over the phone on admission. HISTORY OF PRESENT ILLNESS: Patient is a 85 y.o. female with HX of Vascular Dementia, CVA, DM type II, CKD, HTN, diastolic HF, RA, and Depression  who presents today with increased confusion and neck pain.   The patient was recently admitted to the hospitalist service 1/28/2022 to 1/31/2022 with sepsis, COVID 19, and AKI. There was initially concern for possible intra-abdominal infection in the setting of N/V/D, but CT imaging was negative. She remained on RA over the course of the hospitalization. The patient's AKI improved. She received ABx for possible bacterial PNA. She was discharged home in stable condition. She was prescribed doxycycline at DC.   The patient's daughters live with her. I am unable to obtain Hx from the patient on admission. She is oriented to self only. She denies pain. I reached out to daughter oer the the phone. Who states the pt has had difficulty ambulating for the past 3 days. She was previously able to walk without a walker/cane. No falls/trauma that they are aware of. She has been complaining of neck pain. The patient has been drinking liquids, but not eating her usual amount. She one incontinent stool within the past three days. Otherwise she has not noted any cough/shortness of breath. She reports that her mother is more confused than her baseline. Per notes from most recent admission family to pursue guardianship. The patient has 9 children.   In the ED the patient was febrile with Tmax of 38.7 degrees C. HR was in the 120s. K 5.6. Cr 1.3. Alk phos 232. AST 52. WBC 12.51. Hgb 10.6 and Hct 32.6. Plt 423. CRP 61.4. LA 1.3. Troponin was indeterminate, but flat. UA was negative. EKG with sinus tachycardia. CXR with bilateral infiltrates (stable/mildly improved). CT C spine without contrast without evidence of Fx or traumatic malalignment. OBJECTIVE: BP 167/81  | Pulse 105  | Temp 100.9 °F (38.3 °C) (Oral)  | Resp 16  | Wt 65.4 kg (144 lb 2.9 oz)  | SpO2 97%  | BMI 28.16 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: Hearing normal.     Left Ear: Hearing normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert. She is disoriented.     Comments: Oriented to self only Spontaneously moving all extremities Following basic commands  Psychiatric:     Comments: Flat affect, cooperative