Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Hand deformity, Hyponatraemia, Hypophagia, Immunosuppression, Joint range of motion decreased
Clinical narrative: Hospitalized (5.9.22 - 5.16.22); COVID-19 positive (5.9.22);  fully vaccinated PLUS Booster - moderna x3 Discharge Summary   BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: MD  Admission Date: 5/9/2022 Discharge Date: 5/16/2022   Active Hospital Problems   Diagnosis Date Noted POA ? Sepsis due to Escherichia coli  05/13/2022 Yes ? E coli bacteremia 05/13/2022 Yes ? E. coli UTI 05/13/2022 Yes ? COVID-19   Active Issues Requiring Follow-up Issue: COVID19 Recommended follow-up provider/specialty: PCP What is needed: consider extension of isolation to 21 days given immunosuppression,  Issue: RA Recommended follow-up provider/specialty: Rheum What is needed: Eval timing for next orencia given covid19 infection Issue: New AFIB Recommended follow-up provider/specialty: PCP What is needed: DC on Toprol-xl and eliquis; consider outpatient cardiac monitor once over COVID19 to see if there is any AFIB burden, if not can consider holding above meds  Issue: HTN Recommended follow-up provider/specialty: PCP What is needed: held HCTZ in lieu of metoprolol, if BP elevated can restart DISCHARGE DISPOSITION: Long term care DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hyponatremia [E87.1] Acute cystitis with hematuria [N30.01] Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present [A41.9] COVID-19 [U07.1]   Patient is a wonderful 84 y.o. female admitted with acute respiratory failure with hypoxia secondary to COVID19 PNA.  She has a past medical history of rheumatoid arthritis on methotrexate and monthly Orencia infusions, HTN, obesity.   Patient resides at facility was admitted for severe COVID-19 Pneumonia leading to acute respiratory failure with hypoxemia.  Patient was vaccinated x2 boosted x1. CXR showing abnormal parenchymal opacification of the left lung base as can be seen with pneumonitis. She was placed on supplemental oxygen and Decadron and improved back to room air by time of discharge. She further was also found to have urinary tract infection, blood and urine culture grew E coli susceptible to ceftriaxone.  She completed 7 days of IV antibiotics in hospital.  Patient also was noted to have new onset AFIB.  She was started on eliquis for anticoagulation and metoprolol for rate control.  TTE was essentially normal.     Patient should f/u with her PCP to insure continued resolution of symptoms as well as to monitor BP and possibly restart HCTZ if BP allows (held given metoprolol was started).  Patient will need to review timing of Orencia with her Rheumatologist.   CONSULTS / RECOMMENDATION: IP CONSULT TO CARE MANAGEMENT   INPATIENT PROCEDURES: None VITALS/EXAM DAY OF DISCHARGE: BP 148/73  | Pulse 84  | Temp 36.9 °C (Oral)  | Resp 17  | Ht 1.651 m  | Wt 116.4 kg  | SpO2 99%  | BMI 42.70 kg/m²    Physical ExamVitals and nursing note reviewed.  Constitutional:     General: She is not in acute distress.    Appearance: She is well-developed. She is not diaphoretic.  HENT:    Head: Normocephalic and atraumatic.  Eyes:    General: No scleral icterus. Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rales present. No wheezing.  Abdominal:    General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:      General: Deformity (chronic changes from RA in hands) present.  Skin:   General: Skin is warm and dry.     Findings: No erythema or rash.  Neurological:   Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:       Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.   H&P:  CHIEF COMPLAINT: COVID-19 ASSESSMENT / PLAN:  Acute hypoxic respiratory failure secondary to COVID-19  - vaccinated and boosted x1, symptom onset 5/6 - currently on 2L O2, wean as able - CXR showing abnormal parenchymal opacification of the left lung base as can be seen with pneumonitis - continue decadron - does not meet criteria for remdesivir d/t absence of b/l infiltrates  - dvt prophylaxis, symptomatic treatment - trend daily bmp, crp, d dimer and cbc  LLL opacity - suspect 2/2 atelectasis. Pattern is not consistent with COVID infiltrates  - procal WNL - encourage IS  UTI - previous UA cultures + e cloi with susceptibility to rocephin  - continue rocephin - follow urine culture  Hyponatremia - euvolemic on exam - initial Na 128 - s/p 500cc IVF in ED - repeat bmp, go Na no greater then 136 within 24 hours  Rheumatoid arthritis - receives orencia infusions monthly, recently completed this months infusion - mainly wheelchair bound d/t contractures - hold methotrexate while receiving COVID tx - tylenol prn  Essential HTN - hold hctz d/t hyponatremia - continue losartan  Morbid obeisty - BMI 44.65 - encourage wt loss  Depression/anxiety - continue zoloft  DVT prophylaxis: heparin subq Code status: DNR/DNI Diet: general HISTORY OF PRESENT ILLNESS: Patient is a 84 y.o. female with past medical history of rheumatoid arthritis on methotrexate and monthly orencia infusions, HTN, obesity who resides at facility and presented to the ED with chief complaint of dyspnea and cough. She was subsequently found to have COVID as well as UTI.   Patient reports she started developing a dry cough on 5/6 with progressively worsening dyspnea. Associated symptoms include chills and poor oral intake. She reports multiple residents have tested positive for COVID within the last several days. Denies chest pain, syncope, N/V/D or unilateral lower extremity edema. Patient had COVID 2 years ago and is vaccinated and has had 1 booster shot. In regards to her UTI, patient has a history of recurrent UTI's with cultures positive for e cloi. She does endorse dysuria without hematuria or increased urinary frequency.   Upon arrival to the ED, patient was afebrile and hemodynamically stable on room air. She later became hypoxic to 88% which improved with 2L O2. Labs were notable Na 128, BNP 1,990, WBC 12.94, hgb 10.6, procal 0.15. CXR showed abnormal parenchymal opacification of the left lung base as can be seen with pneumonitis. Blood cultures and urine culture were obtained. Patient received 500cc IVF in addition to rocephin and decadron.  Review of Systems Constitutional:  Positive for appetite change and chills. Negative for fever.  HENT: Negative for congestion and rhinorrhea.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for sputum production.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Positive for joint pain (chronic d/t RA). Negative for falls.  Neurological:  Negative for dizziness, light-headedness and numbness/tingling.  Skin:  Negative for rash and wound.  OBJECTIVE: BP (!) 114/45  | Pulse 88  | Temp 98.1 °F (36.7 °C) (Oral)  | Resp 16  | Wt 118 kg (260 lb 2.3 oz)  | SpO2 96%  | BMI 44.65 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not toxic-appearing.     Comments: Resting comfortably in bed, daughter at bedside   HENT:     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     General: No scleral icterus.    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: No wheezing or rales.     Comments: Breathe sounds diminished throughout all lung fields secondary to body habitus  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.     Comments: Hypoactive bowel sounds  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.     Comments: Multiple contractures to BUE and BLE ROM limited 2/2 contractures, unable to bend knees and is wheel chair dependent at baseline  Skin:    General: Skin is warm and dry.     Coloration: Skin is pale.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Comments: Follows basic commans