Age: 79.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Gastrointestinal tube insertion, Gastrointestinal tube removal, Gastrostomy, General physical health deterioration
Clinical narrative: Patient is a 80 y.o. male who presented from home on 3/8/2023 with shortness of breath and cough. Found to have COVID19 PNA. Improved with dexamethasone and antibiotics. Course complicated by chronic dysphagia. SLP followed. Cor flo placed 3/13. GI consulted for PEG placement which occurred on 3/20. Neurology consulted for evaluation of possible MG, with plans to follow up outpatient. He received IVIG inpatient x5 days and minimal improvement after IVIG. Patient appropriate for discharge on 3/21. SNF acceptance 3/22. Plan for outpatient follow up with Neurology, ENT, GI. Repeat CMP in one week   Dysphagia/dysphonia Possible Myasthenia Gravis Unilateral vocal cord paralysis. Per history.  Established with ENT.  -MBS on 3/12 demonstrated severe dysphagia in the pharyngeal region, compared to the previous study on 2/2/2023 there has been a significant decline in the pharyngeal swallow function -admissions previously for dysphagia in 2022 with some suspicion of TVC paralysis, dysmotility, possible cricopharyngeal bar and reflux -1/26/22 s/p flexible fiberoptic laryngoscopy; diagnosed with left TVC paralysis with Dr.  -Esophagram 1/26/22 also revealed large cricopharyngeal bar but no findings of obstruction -MBS (2/1/22) with moderate pharyngeal and esophageal dysphagia with recommendations for ground mechanical diet and thin liquids. Noted to have osteophyte at C3/4 impacting pharyngeal contraction; also noted to have suspected cricopharyngeal bar -CT neck (1/31/22) without evidence for soft tissue mass or enhancement  -s/p EGD 2/15/22 showing diverticulum in the middle third of the esophagus, suggestive of esophageal dysmotility. No mass, ring, stricture noted. - CorFlo placed 3/13. Removed withPEG placement 3/20 by GI. Neurology followed for possible MG; IVIG empirically x5 completed 3/20. Stopped mestinon due to nausea. Unable to fully tolerate EMG. Serologies PENDING on discharge. ENT recommending OP follow up. Neuro recommending OP follow up. Continue speech therapy   Sepsis due to COVID-19 infection - resolved COVID-19 associated multifocal pneumonia - resolved Acute hypoxemic respiratory failure - resolved Onset of illness unclear.  Patient was feeling ill for several weeks. Positive test on admission. He is vaccinated. -Requiring supplemental oxygen on admission, weaned to room air on 3/10 -Dexamethasone 6 mg daily x10 days total. Remdesivir was stopped on day of admission. -Completed 5 day Rocephin course.  -Isolation removed.   Hyponatremia Likely pseudohyponatremia from IVIG. Possible component of diminished PO intake and tube feeding - Na 132 on discharge - repeat CMP one week from DC   Elevated transaminase - improving Likely secondary to COVID19 virus. No abdominal symptoms -ALT 57 on discharge - repeat CMP one week from DC   Severe Malnutrition, POA Secondary to above. Dietician following - CorFlo placed 3/13 switched to PEG placement on 3/20. Dietician followed. Diet recs on discharge: NPO with PEG tube feeds Depression - Home med includes lexapro 10mg, continued inpatient - Patient's significant other does relay concerns about the patient being significantly depressed.  She has mentioned this a few times up to this point has not been endorsing SI.  She states that he becomes very withdrawn and has been having difficulty since he has been experiencing decline in his health. - No SI/HI - titrate regimen outpatient   Essential hypertension Home medications include metoprolol. -Held metoprolol on discharge, normotensive   Non hodgkin's lymphoma of Neck - Diagnosed in 2015 - Completed rituximab. -  Follows with Dr., last seen 11/22. Continue follow up   Ascending Thoracic Aortic Aneurysm - Follows outpatient with cardiothoracic surgery - CT dissection 1/29/23 with pelvis shows 4.4 x 4.4 diffuse aneurysmal dialation - Continue to follow up with CT Surgery Dr    AKI - resolved Prerenal, secondary to above. -Baseline SCR around 0.9.  SCR on admission 1.3. -S/p fluid bolus in the emergency department.  -Repeat Cr normalized   Elevated lactic acid - resolved Secondary to above, without acidosis. -Lactic acid 6.0 on admission.  S/p fluid bolus in the emergency department. -Repeat lactic acid 1.8.