Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Angiogram cerebral abnormal, Anion gap, Arteriogram carotid abnormal, Arteriosclerosis
Clinical narrative: Hospitalized (2.16.22 - 2.18.22 - readmitted 2.22.22-2.24.22); COVID-19 positive (2.16.22); fully vaccinated PLUS Booster -moderna x3 d/c summary from 2.24.22:  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: PA-C Admission Date: 2/22/2022 Discharge Date: 2/24/2022   HOSPITAL PROBLEMS 1. Weakness 2. Confusion 3. COVID-19 4. Acute hypoxic respiratory failure 5. Schizoaffective disorder, bipolar type 6. Insulin-dependent type 2 diabetes mellitus 7. Asthma/chronic obstructive pulmonary disease 8. Hypertension 9. Hyperlipidemia 10. Heart failure preserved ejection fraction 11. History of pulmonary embolism  PROCEDURES Chest x-ray (2/22):  No acute intrathoracic process CT Head (2/22):  No acute intracranial abnormality.  Chronic changes. CTA H/N (2/22):  Mild atherosclerotic plaque.  No evidence of large vessel occlusion or hemodynamically significant stenosis   CONSULTS IP CONSULT TO SOCIAL WORK IP CONSULT TO CARE MANAGEMENT DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 71 y.o. female with a recent admission for COVID-19 presenting with increased weakness, confusion. -Weakness:  Likely secondary to deconditioning related to COVID-19.  Presenting with difficulties completing activities of daily living.  Worked with Physical and Occupational therapy during hospitalization, recommending subacute rehab upon discharge.   -Confusion:  Daughter concerned this may be medication induced as she had recent change in medication regimen.  Did decrease home Lexapro back to previous dose of 5 mg.  To believe there is a component of COVID-19 playing a role in addition to being on steroids for treatment of COVID-19.  Completed course of steroids on 2/24.  Continue to monitor for improvement in mentation. -COVID-19:  Admitted from 2/16-2/18 for treatment of COVID-19 pneumonia.  Discharge on room air.  Readmitted for weakness.  Completed 10 day course of Decadron on 2/24.  Did require supplemental oxygen during hospitalization, which was gradually weaned to room air prior to discharge.  Patient day 10-11 of symptoms upon discharge.  -Schizoaffective disorder:  Follows with psychiatry.  Recently weaned off Zyprexa nightly.  Continued home medications during hospitalization.  Did decrease Lexapro back to previous dose of 5 mg daily per daughter's preference.  Did not require any p.r.n. medications for agitation.   BP 159/83  | Pulse 80  | Temp 36.6 °C (Oral)  | Resp 20  | Ht 1.651 m  | Wt 70 kg  | SpO2 99%  | BMI 25.68 kg/m²   DISCHARGE RECOMMENDATIONS: Close follow-up with Psychiatry upon discharge  Continue PT/OT  DISCHARGE DISPOSITION: Subacute rehab-   CONDITION ON DISCHARGE: Stable  2.22.22 H&P:  CHIEF COMPLAINT: Weakness HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old female with PMH of schizoaffective disorder, hypertension, diabetes, chronic obstructive pulmonary disease, CHF that presented to the ED for generalized weakness.  History obtained from chart review as patient provides minimal information regarding the events leading up to today's presentation to the ED, there is no family or visitors at bedside, and unable to contact via phone.  According to the ED provider, patient was diagnosed with COVID-19 infection on 02/16/2022 with a 2 night hospitalization at that time.  She was discharged home with home PT/OT.  Today she presented with her daughter at bedside for evaluation of severe weakness that has progressively gotten worse since hospital discharge 4 days ago.  She is unable to get out of bed without significant assistance.  Although she does have home physical and occupational therapy she needs additional help with her activities of daily living and requires 24 hour assistance.  Her daughter additionally noted that she has noticed some swelling in her legs and felt like her cognition was slower than normal.  CT head in ED demonstrated no acute intracranial abnormality.  Chronic changes.  CXR with no acute intrathoracic process.  UA and WBC were unremarkable.  D-dimer was 350.  According to the emergency department provider, the patient's family's felt that it was unsafe for her to return home at this time and are seeking inpatient rehab placement.  Social work was consulted but there is no availability to find placement from the emergency department and they requested admission awaiting placement.     At the time of my assessment patient is A & O to person, place, time but is slow to respond.  When I asked why she presented to the ED today she states "I had to" and when asked clarifying question about why she "had to" she stated "they'll beat me" She did not repeat this when asked for clarification.   Review of Systems Review of Systems Constitutional:  Negative for chills and fever.  HENT: Negative for sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Negative for cough and shortness of breath.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Negative for muscle pain.  Neurological:  Negative for headaches, light-headedness and speech difficulty.  Skin:  Negative for rash.  OBJECTIVE:   Physical Exam BP 121/87  | Pulse 80  | Temp 37.1 °C (Oral)  | Resp 20  | Ht 1.651 m  | Wt 70 kg  | SpO2 93%  | BMI 25.68 kg/m²    Physical Exam Constitutional:  General: She is not in acute distress. HENT: Head: Normocephalic.  Eyes: Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular: Rate and Rhythm: Normal rate.     Pulses: Normal pulses.     Heart sounds: No murmur heard.   No friction rub. No gallop.  Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress.  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: Comments: Moves all extremtiies  Skin: General: Skin is warm and dry.  Neurological:  Mental Status: She is alert.     Comments: A & O to person, place, time.  Delayed in answering questions at times. Rhythmic tongue movements.  Grip strength and leg strength strong and equal.  Face symmetrical.   Psychiatric:     Comments: Delayed in answering questions, will follow commands  ASSESSMENT/PLAN: Weakness   - recently diagnosed with Covid-19 and completing decadron               - no focal deficits              - PT/OT              - Social work consult - patient endorsed "I had to" when asked why she came to ED and when asked clarifying question about why she had to she stated "they'll beat me".  Per note, family is looking at facility but I have not been able to talk to them regarding placement. Schizoaffective disorder   - start home Clozaril and escitalopram Covid 19   - continue Decadron course(2 days left) DM2   - start home Lantus of 14 u daily              - will start low dose corrective and adjust as needed              - AC & HS accuchecks Asthma/COPD   - home budesonide to  Fluticasone per formulary HTN   - not on medication HLD    - simvastatin VTE PPx: start home Xarelto   2/18/22 D/c summary:DISCHARGE SUMMARY   BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider at Discharge: PA-C Admission Date: 2/16/2022 Discharge Date: 2/18/2022   HOSPITAL PROBLEMS 1. Acute hypoxic respiratory failure 2. COVID-19 Infection 3. COPD 4. Hx of PE 5. T2DM 6. Schizoaffective disorder 7. Stage 3 CKD 8. Hyperlipidemia PROCEDURES/IMAGING CXR: Minimal left infrahilar atelectasis   CONSULTS IP CONSULT TO CARE MANAGEMENT DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 71 y.o. female admitted Covid-19 infection. Patient had originally presented with weakness, and had cough over the past few days. Was diagnosed with Covid in ED. She was initiated on 10 day course of decadron as she was requiring oxygen via nasal cannula. Was seen by PT/OT who recommended home with home health, PT/OT. She was able to wean off oxygen evening before discharge.    BP 129/80  | Pulse 81  | Temp 36.9 °C (Oral)  | Resp 20  | Ht 1.626 m  | Wt 70.5 kg  | SpO2 97%  | BMI 26.68 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is normal weight.  HENT:     Head: Normocephalic.     Nose: No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal.     Comments: Coarse breath sounds bilaterally, improved Abdominal:     General: Abdomen is flat. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness.     Right lower leg: Edema (Mild) present.     Left lower leg: No edema.  Neurological:     Mental Status: She is alert.   DISCHARGE RECOMMENDATIONS: Complete 10 day course of Decadron (7 days remaining) Follow up with PCP for resolution of pulmonary symptoms DISCHARGE DISPOSITION: Home with services - Nursing, Occupational therapy and Physical therapy CONDITION ON DISCHARGE: Stable