Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Dysstasia, Essential hypertension, Exostosis, Fall, Gait inability
Clinical narrative: Age: 79 y.o. Admit Date: 7/24/2022  3:51 PM Discharge Date:  8/3/2022   Discharge Diagnosis: Principal Problem:   COVID-19 virus infection Active Problems:   Essential hypertension, benign   Sensorineural hearing loss (SNHL) of both ears   Dementia with psychosis       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 79 y.o. male presents from assisted living.  He was diagnosed with covid and has become very weak.  He is in assisted living and is unable to stand or transfer.  Staff tried to stand him here and he could not stand.  History from him is limited due to hearing and dementia"   Hospital Course: Patient is a 79 y.o. male who presented with weakness, COVID-19 infection.  He was managed for the following:   * COVID-19 virus infection COVID-19 infection - Patient positive for COVID-19 on admission.  He was on room air.  He was treated with 5 days remdesivir, completed 7/28.  Remained stable.     Debility - patient was sent from his personal care home due to inability to walk. PT evaluated patient.  He will go to SNF at healthcare facility on discharge.     Dementia - chronic.     HTN - controlled, continue home meds         Physical Exam on the Date of Discharge: Blood pressure 156/80, pulse 58, temperature 97.9 °F (36.6 °C), temperature source Oral, resp. rate 18, height 5' 9" (175.3 cm), weight 92.8 kg (204 lb 9.4 oz), SpO2 98 %. General - NAD, appears stated age HEENT - EOMI, PER, MMM, hard of hearing Chest - lungs clear bilaterally,  Heart - RRR,  Abdomen - Soft, non-tender, Extremities - warm, no edema Psych - affect appropriate Skin - no rash, dry   Discharge Condition: improved   Disposition: SNF   CONSULTS DURING ADMISSION:  IP CONSULT TO SOCIAL WORK IP CONSULT TO SOCIAL WORK   IMAGING / PROCEDURES / RESULTS:     CT Head WO Contrast   Result Date: 7/24/2022 PROCEDURE INFORMATION: Exam: CT Head Without Contrast Exam date and time: 7/24/2022 6:05 PM Age: 79 years old Clinical indication: Altered mental status/memory loss; Prior surgery; Surgery type: Right and left cornea, tonsillectomy, rhinoplasty TECHNIQUE: Imaging protocol: Computed tomography of the head without contrast. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. COMPARISON: CT HEAD WO CONTRAST 3/24/2021 12:23 AM FINDINGS: Brain: Age related brain involution is present. No acute intracranial hemorrhage, mass effect, midline shift, or brain herniation. Diffuse subcortical and periventricular white matter hypodensities are most in favor with chronic small vessel disease. Intracranial atherosclerosis is present. Cerebral ventricles: There is ex vacuo ventriculomegaly. Paranasal sinuses: There is fluid within the sinuses, consistent with sinusitis. Mastoid air cells: The mastoid sinuses are clear. Orbital cavities: There have been bilateral intraocular lens replacements. Bones/joints: No acute skeletal abnormality or aggressive osseous lesion. Soft tissues: There is no significant soft tissue swelling.    IMPRESSION: No acute intracranial pathology.  on 07/24/2022 06:26 PM   XR Portable Chest   Result Date: 7/24/2022                                                                                          07/24/2022                       ORDERING PHYS:   Portable chest  Comparison 10/22/2020  History:  Shortness of air  Findings:  There is shallow inspiration without definite acute abnormality.  Impression:  No definite acute abnormality.               THIS IS AN ELECTRONICALLY VERIFIED REPORT               7/24/2022 4:58 PM:  DD:  07/24/2022 TD:  07/24/2022                                     Radiology Page 1    of   1                                                          COPY   XR Hip Bilateral 2 VW   Result Date: 7/24/2022 PROCEDURE INFORMATION: Exam: XR Bilateral Hips Exam date and time: 7/24/2022 9:33 PM Age: 79 years old Clinical indication: Pelvic pain; Additional info: Fall TECHNIQUE: Imaging protocol: Radiologic exam of the bilateral hips. Views: 2 views of hips with pelvis when performed. COMPARISON: CR XR HIP LEFT 2 VW 3/23/2021 9:11 PM FINDINGS: Bones/joints: Complete left hip arthroplasty. No evidence of hardware complications. Specifically, no evidence for hardware loosening or periprosthetic fractures. Mild osteoarthritis of the right hip joint, as manifested by decreased joint space, subchondral sclerosis, and marginal osteophyte formation. There is no evidence of acutely displaced skeletal fractures. There is no evidence of joint dislocation. No aggressive osseous lesions. Soft tissues: There is no significant soft tissue swelling.    IMPRESSION: No acute skeletal pathology or hardware complications. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED on 07/24/2022 09:50 PM             LABS AT TIME OF DISCHARGE:   Lab Results Component Value Date   WBC 6.3 08/03/2022   HGB 14.4 08/03/2022   HCT 43.5 08/03/2022   MCV 96.7 08/03/2022     Lab Results Component Value Date   SODIUM 140 08/03/2022   POTASSIUM 4.0 08/03/2022   CHLORIDE 107 08/03/2022   CO2 25 08/03/2022   GLUCOSE 119 (H) 08/03/2022   BUN 14 08/03/2022   CREATININE 0.7 08/03/2022   CALCIUM 8.6 08/03/2022   TBILIRUBIN 0.5 08/03/2022   ALP 71 08/03/2022   AST 23 08/03/2022   ALBUMIN 3.4 08/03/2022     Lab Results Component Value Date   INR 1.0 07/24/2022   INR 1.0 10/03/2020     Microbiology Results (last 14 days)    Procedure Component Value Units Date/Time   SARS-CoV-2, QL, PCR (STAT) (Abnormal) Collected: 07/24/22 1711   Order Status: Completed Specimen: Nasopharyngeal from Nasophayngeal Updated: 07/24/22 1755     SARS-CoV-2 RNA Detected      Comment:   Reference value:  Undetected   Testing was performed using the GeneXpert Dx System.   Fact sheets for this Emergency Use Authorization (EUA) assay can be found at the following links:         Test Performed by:       Narrative:     Called to and read back by Pt., at 17:55 on 07/24/2022,  Symptomatic?->Yes Indications (select all that apply)->Admission NO KNOWN ALLERGIES       MEDICATIONS AND ORDERS   Current Discharge Medication List   CONTINUE these medications which have CHANGED   Details diazePAM (VALIUM) 5 mg tablet Take 1 Tablet by mouth At bedtime. Qty: 5 Tablet, Refills: 0   Associated Diagnoses: Anxious mood   QUEtiapine (SEROQUEL) 50 mg Tab tablet Take 50 mg by mouth Twice a day. Qty: 60 Tablet, Refills: 0   Associated Diagnoses: Dementia with psychosis     CONTINUE these medications which have NOT CHANGED   Details Omega-3-DHA-EPA-Fish Oil (FISH OIL) 1,000 (120-180) mg Cap Take 1,000 mg by mouth Once Daily.   divalproex (DEPAKOTE) 125 mg DR EC tablet Take 125 mg by mouth At bedtime.   furosemide (LASIX) 40 mg tablet Take 40 mg by mouth Once Daily.   memantine (NAMENDA) 10 mg Take 10 mg by mouth Twice a day. Morning and bedtime   omeprazole (PRILOSEC) 20 mg DR capsule Take 20 mg by mouth Once Daily.   potassium chloride (KLOR-CON) 10 mEq tablet Take 10 mEq by mouth Once Daily.   donepeziL (ARICEPT) 5 mg Take 5 mg by mouth At bedtime.   bisacodyL (DULCOLAX) 10 mg suppository Insert 10 mg rectally Every 3 days as needed for Constipation.   sodium phosphates (FLEETS) 19-7 gram/118 mL Enem enema Insert 1 Enema rectally Every 3 days as needed for Constipation.   magnesium hydroxide (MILK OF MAGNESIA) suspension Take 30 mL by mouth Every 3 days as needed for Constipation.   Polyethylene Glycol 3350 (GLYCOLAX) 17 gram/dose powder Take 17 g by mouth Daily. Dissolve completely in 8 ounces of liquid   ibuprofen (ADVIL) 200 mg tablet Take 2 Tabs by mouth Three times a day as needed for Pain. Qty: 100 Tab, Refills: 3   Associated Diagnoses: Hip pain, acute, left   tamsulosin (FLOMAX) 0.4 mg capsule Take 1 Cap by mouth Daily. Qty: 30 Cap, Refills: 0   Associated Diagnoses: Retention of urine   Cyanocobalamin 500 mcg Tab Take 500 mcg by mouth Daily.   Associated Diagnoses: Dementia with psychosis   docusate sodium (COLACE) 100 mg capsule Take 100 mg by mouth Once daily as needed.   escitalopram oxalate (LEXAPRO) 10 mg tablet Take 10 mg by mouth Daily.   Associated Diagnoses: Dementia with psychosis   metoprolol (LOPRESSOR) 25 mg tablet Take 37.5 mg by mouth Twice a day. Hold for HR < 60   Associated Diagnoses: Essential hypertension, benign   guaiFENesin (MUCINEX) 600 mg Take 600 mg by mouth Twice a day.   Budesonide-Formoterol (SYMBICORT 160-4.5 MCG) 160-4.5 mcg/Actuation inhaler Take 2 Puffs by inhalation Every 12 hours. Qty: 3 Inhaler, Refills: 3   Associated Diagnoses: Mild intermittent asthma without complication   atorvastatin (LIPITOR) 10 mg tablet Take 5 mg by mouth At bedtime.   fluticasone (FLONASE) 50 mcg/Actuation nasal spray Spray 2 Sprays in nose Daily. (in each nostril)   MULTIVITAMIN WITH MINERALS (ONE-A-DAY 50 PLUS PO) Take 1 Tab by mouth Daily.