Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Acute kidney injury, Acute sinusitis, Alanine aminotransferase increased, Anion gap, Anxiety
Clinical narrative: Hospitalized (1.3.22 - 1.7.22); COVID-19 positive (1.3.22); Fully vaccinated - J&J X1 d/c summary: Discharge Summary PA-C (Physician Assistant-Certified) ? ? General Medicine Cosigned by: MD, MPH at 1/7/2022 11:23 AM    BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: DO Admission Date: 1/3/2022 Discharge Date: Jan 7, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Generalized weakness and fall 01/03/2022 Yes ? COVID-19 01/03/2022 Yes ? Paroxysmal A-fib    Yes ? Anxiety and depression 12/28/2021 Yes ? Chronic gout of left foot, unspecified cause 10/21/2021 Yes ? Biventricular ICD (implantable cardioverter-defibrillator) in place 05/20/2019 Yes ? Controlled type 2 diabetes mellitus without complication, with long-term current use of insulin  03/19/2018 Yes ? Essential hypertension with goal blood pressure less than 130/85 09/14/2016 Yes ? CAD (coronary artery disease) and ischemic cardiomyopathy s/p CAGBx5  05/07/2015 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute kidney injury superimposed on CKD  08/05/2019 01/07/2022 Yes    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Current severe episode of major depressive disorder without psychotic features without prior episode  12/28/2021 Unknown ? Bereavement 12/28/2021 Unknown ? Right elbow pain 12/28/2021 Unknown ? Opioid use 11/16/2021 Unknown ? Bilateral foot pain 10/21/2021 Unknown ? Myopericarditis 05/27/2021 Unknown ? Finger amputation, no complication 03/16/2021 Unknown ? Longstanding persistent atrial fibrillation  11/10/2020 Unknown ? Shortness of breath 05/31/2019 Unknown ? Cardiomyopathy, ischemic 05/31/2019 Unknown ? Cardiac arrest with ventricular fibrillation  05/17/2019 Unknown ? NSTEMI (non-ST elevated myocardial infarction)  05/08/2019 Unknown ? Mild nonproliferative diabetic retinopathy of both eyes without macular edema associated with type 2 diabetes mellitus (HCC) 10/12/2018 Unknown ? Statin intolerance 09/19/2018 Unknown ? PMR (polymyalgia rheumatica)  06/03/2015 Unknown ? Osteoarthrosis, unspecified whether generalized or localized, unspecified site 05/07/2015 Unknown ? Sleep apnea 05/07/2015 Unknown ? Chronic back pain 05/07/2015 Unknown     Discharge Disposition:  skilled nursing facility    Active Issues Requiring Follow-up: Diabetes     DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness [R53.1] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 70 y.o. male with PMH of paroxysmal HTN, ischemic cardiomyopathy s/p ICD placement, A. Fib, DM II, CKD IIIb, gout, anxiety/depression. He was admitted on 1/3/22 at Hospital Emergency Department with generalized weakness for 1 week. His wife passed away on Christmas day from sepsis and he has gradually been declining since. They were able to postpone her funeral so he did not miss it.             In the ER patient tested positive for COVID, although he was fully vaccinated. CXR showed mildly increased hazy opacity of the left lung base which could represent developing infiltrate versus low inspiratory volumes. No focal consolidation. He did not develop any significant symptoms of COVID-19 and was on RA, therfore did not receve decadron or remdesivir. He had CT head: 1.  Mild atrophy. 2.  Mild/moderate white matter disease and some smaller areas of volume loss, likely chronic small vessel ischemic changes. 3.  Negative for acute intracranial process. No acute traumatic findings status post fall. 4.  Mild acute and/or chronic right sphenoid sinusitis.    PT/OT recommended skilled nursing facility where he was transferred on 1/7/22 to Facility.He had some hyponatremia, hypokalemia and AKI on CKDI IIIb. He was started on spironolactone 25 mg daily and Imdur was cut to 30 mg daily due to lower BP. His metolazone was held due to his AKI. He was discharged on lasix and aldactone and metolazone was stopped. His sodium and potassium normalized and his renal function is improved. His blood pressures are stable on day of discharge. A. Fib was well controlled, continued on his home metoprolol, Eliquis. DM type II uncontrolled. Hgb. A1c 9.8 in 11/21 and he is normally on 70/30. He has been on 40 units of lantus and moderate corrective insulin here and his  blood sugars are well controlled. He was discharged on lantus and corrective insulin. Case management will have his facility ensure cost of insulin prior to leaving SAR. He will need prior auth for the corrective insulin. Recommend that he have repeat BMP on 1/10 to check renal function and potassium with recent medication changes. Patient is clinically improved and hemodynamically stable for discharge. He notes that he is feeling the best he has in the last few days.  Discussed plan of care for discharge with patient including outpatient follow-up with PCP within 7 days.  Patient voiced understanding and was agreeable with plan of care for discharge.   Consults: None    Procedures: None  BP 131/93  | Pulse 73  | Temp 36.8 °C (Oral)  | Resp 22  | Ht 1.638 m  | Wt 97.2 kg  | SpO2 100%  | BMI 36.21 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is obese.     Comments: Appears fairly comfortable but fatigued lying in bed though appears improved from admit   HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Thyroid: No thyromegaly.     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard.     Comments: No lower extremity edema Pulmonary:     Effort: Pulmonary effort is normal. No tachypnea or respiratory distress.     Breath sounds: Normal breath sounds. No rhonchi or rales.     Comments: Occasional wheeze noted on expiration. He is on room air  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  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.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Speech: Speech normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.     Comments: Pleasant    H&P: CHIEF COMPLAINT: Generalized weakness   Full code, no prolonged life support      Assessment/Plan    ASSESSMENT / PLAN: * Generalized weakness and fall Assessment & Plan PT/OT ordered will likely need placement  He is COVID positive. He would like to be able to go home His wife recently died and her funeral is on Thursday. Social work consulted as well as part of his decline was felt to be due to grief  Continue supportive care for COVID  CT head negative in the ER    COVID-19 Assessment & Plan Imaging is not showing COVID pneumonia. He tested positive for COVID 1/3 Could be contributing to his weakness  Had some mild leukocytosis in the ER but was afebrile and normal HR and RR. On steroids for gout flare so could be driving up WBC  He is vaccinated and presented with weakness and falls Does not meet criteria for dexamethasone or remdesivir. If he develops hypoxia, consider  Continue supportive care Continue to monitor daily labs including CMP, CBC, D-dimer Lovenox for VTE prophylaxis for now and switch to therapeutic treatment as needed  Currently on room air, use oxygen PRN     Paroxysmal A-fib  Assessment & Plan Continue Metoprolol and Eliquis  Continue to monitor    Anxiety and depression Assessment & Plan Continue Cymbalta and ativan Social work consulted. Patient has been struggling since the recent death of his wife Wife's funeral is this Thursday and patient would like to attend    Chronic gout of left foot, unspecified cause Assessment & Plan Continue allopurinol Recently treated with steroids for gout, continue   Acute kidney injury superimposed on CKD  Assessment & Plan Cr 2.04 and baseline is closer to 1.6 Given IVF in the ER Limit fluids with COVID but monitor Monitor renal function closely and renally dose medications Avoid nephrotoxic agents as able    Biventricular ICD (implantable cardioverter-defibrillator) in place Assessment & Plan ICD in place  History of PAF, bradycardia and Mobitz I   Controlled type 2 diabetes mellitus without complication, with long-term current use of insulin   Assessment & Plan Normally on 70/30 30 units TID Will place on 36 units of lantus and moderate corrective insulin Continue to monitor blood sugar and adjust insulin as needed    Essential hypertension with goal blood pressure less than 130/85 Assessment & Plan Continue Metoprolol Hold Metolazone and lasix Continue to monitor blood pressure    CAD (coronary artery disease) and ischemic cardiomyopathy s/p CAGBx5  Assessment & Plan He also has history of NSTEMI and Vfib arrest now ICD in place Continue metoprolol, plavix, statin and Eliquis Holding lasix and metolazone due to AKI resume when able Continue Imdur           Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 70 y.o. male who presents today with weakness for the last week. He notes that his wife passed away on Christmas day from Sepsis. He notes that since the last 2 weeks he has had "uncontrollable shaking" and weakness. He denies fever or chills. He has had some coughing but mild and occasionally feels SOB but states "that is due to congestive heart failure and prior cardiac arrest." He denies chest pain, palpitations or tachycardia. He states "I had chest pain the day my wife passed and took nitro to take care of the pain" but denies pain since. He notes that his wife did not have COVID and he is unaware of any sick contacts. He is vaccinated and his last dose was in May he thinks. He states "after I had the vaccine I had myocarditis." He denies LE edema. He has had some falls frequently and notes "I fell today and yesterday I feel 3 or 4 times." He notes that he injured his left pinky. He did hit his head yesterday "it doesn't hurt anymore but it did." He is uncertain if he passed out when he fell. He notes that he fell walking to his room and states "I told my daughter I cant stand up and next thing I knew I was on the floor." He denies facial droop, slurred speech, confusion or unilateral weakness but has noticed generalized weakness. He is having body aches. Patient notes that his wife's funeral is on Thursday and he would really like to go. Told him that since he is COVID positive even if he is feeling better he should not go to the funeral. Encouraged patient and daughter that they reschedule the funeral if able.    In the ER patient tested positive for COVID. He had CXR showed This mildly increased hazy opacity of the left lung base which could represent developing infiltrate versus low inspiratory volumes. No focal consolidation. Procalcitonin was WNL so likely not bacterial. He had head CT also negative for acute process but showed some chronic changes. His labs did show an AKI. His weakness was felt to be due to his COVID. He will be admitted for observation of COVID and weakness. He is currently on room air Review of Systems Constitutional:  Positive for appetite change (decreased, he did eat some soup yesterday), chills and fatigue. Negative for fever.  HENT: Negative for congestion, rhinorrhea and sore throat.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing and chest tightness.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Positive for nausea, vomiting (just a little bit this morning) and constipation. Negative for abdominal pain, diarrhea and blood in stool.  Genitourinary:  Negative for difficulty urinating, dysuria and hematuria.  Musculoskeletal:  Positive for falls.       Body aches all over .  Neurological:  Positive for headaches, dizziness and weakness.  Psychiatric/Behavioral:  Positive for depression (wife recently died) and sleep disturbance.  Skin:  Negative for rash.       Bruises all over. Pinched left pinky in hall closet and has wound from that. He denies other opened sores .          Objective    OBJECTIVE: BP 151/77  | Pulse 81  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.638 m  | Wt 99 kg  | SpO2 100%  | BMI 36.88 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is obese. He is ill-appearing.     Comments: Appears fatigued laying on stretcher in the hall in the ER  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Thyroid: No thyromegaly.     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard.     Comments: No lower extremity edema Pulmonary:     Effort: No tachypnea or respiratory distress.     Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales.     Comments: Lungs are fairly clear, no wheezing or rhonchi. He is on room air  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.     Comments: Equal grip strength and plantar flexion bilaterally but generalized weakness noted   Skin:    General: Skin is warm and dry.     Findings: No rash.     Comments: Abrasion to left pink, bandage in place   Neurological:     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.     Comments: No facial droop, slurred speech, confusion or unilateral weakness. No pronator drift   Psychiatric:        Speech: Speech normal.        Behavior: Behavior normal.        Judgment: Judgment normal.     Comments: Pleasant but slightly depressed