Age: 68.0
Sex: M
Vaccine: COVID19
Symptoms: Electrolyte substitution therapy, Feeling cold, Gait disturbance, Headache, Hypotension
Clinical narrative: Moderna Dose 1 2/8/21 (038K20A) Moderna Dose 2 3/9/21 (038K20A) COVID Positive 1/9/22  1/9/22: Patient is a 69-year-old male with past medical history significant for type 2 diabetes mellitus, hypertension, OSA on CPAP, CAD s/p bypass grafting, hyperlipidemia, Hx CVA with right-sided weakness, depression, hx diarrhea, obesity has come to the emergency room with complaints of cough, diarrhea and increased weakness for 3 days.  Patient has dysarthric speech and at times difficult to understand. Some of the information has been gathered from the emergency room providers report and a phone call to patient's wife.  Patient told me that the reason for him coming to the hospital was because of the diarrhea.  He also admits to cough and shortness of breath. He is unable to contribute much to the history. Patient's wife reports that patient was at baseline assisted with a gait belt and 1 person assist to ambulate.  He started having generalized weakness since Friday he also complained about headache and feeling of cold.  Patient had to be put in a wheelchair for getting him to the bathroom from Friday.  Patient did not have any appetite.  He had nasal drainage on Friday.  He started having cough yesterday and this morning he had multiple episodes of loose stools that she had to change the diapers multiple times.  His wife also reports that she herself and her grandson sick and having fevers, cough and stuffy nose and sore throat that they are worried about COVID-19.  Patient apparently is a vaccinated for COVID-19 with Moderna vaccine  x2.  He did not receive a booster dose.  Patient denied any chest pain or palpitation.  He denied any abdominal pain or headache at my exam.  He denied any nausea or vomiting.  In the emergency room patient was noted to have mild dehydration with a creatinine elevated to 1.4. Mild potassium deficiency at 3.3.  Patient did not have any leukocytosis. His COVID test is pending.  Patient was hypotensive in the 70s to 90s systolic while in the ER.  His O2 saturations were low 90s on room air and was placed on 2 L O2 nasal cannula. He is being admitted for further management.  1/19/22:  69-year-old male with past medical history significant for type 2 diabetes mellitus, hypertension, OSA on CPAP, CAD s/p bypass grafting, hyperlipidemia, Hx CVA with right-sided weakness, depression, hx diarrhea, obesity has come to the emergency room with complaints of cough, diarrhea and increased weakness for 3 days. He tested positive for COVID-19. He is noted to have hypotension and also developed hypoxemia in the emergency room.  Patient had to be started on oxygen. He was on IV pressors and IV fluids overnight in the emergency room on 1/9/22.  Patient was noted to have right lung pneumonia thought to be from COVID-19 infection. Patient was started on remdesivir and IV Decadron.  He was also started on azithromycin and Rocephin. He needed the multiple electrolyte replacements. He needed up to 15 L high flow oxygen on 1/9/22. His kidney function recovered with IV fluids.  The patient was needing between 3-4 L of oxygen on the medical floor.  Patient was vaccinated for COVID-19.  Patient had positive blood cultures but the final report came back as Coag-negative staph with 2 different species.  Patient was started on vancomycin which was discontinued after the repeat cultures were negative. He improved over the next few days and was the restarted back on his blood pressure meds.  He was weaned from oxygen.  He is s/p remdesivir.  He he has complete IV Decadron as of today.  Patient was accepted at a skilled nursing facility is and is planned for discharge today.