Age: 91.0
Sex: M
Vaccine: COVID19
Symptoms: Fluid intake reduced, Full blood count normal, Influenza virus test negative, Malaise, Metabolic function test abnormal
Clinical narrative: The patient is a 91 y male presented to the ED with complaints of fatigue, chills and increased cough. Spoke with the patient's daughter over the phone for the patient's history. The patient comes today from his nursing home where he had a positive COVID-19 test yesterday. 2 of the staff at the home had recently tested positive. The patient has had generalized weakness and fatigue over the last few days. He has a chronic cough which has become productive. The patient is otherwise symptomatic. The patient's daughter stated that they wanted a confirmation of his COVID-19 through a PCR test, as he had his booster vaccination last week. COVID-19, RSV and Influenza tests and a chest x-ray were ordered for evaluation of the patient's fatigue and productive cough. An IV was established.    The chest x-ray was reviewed by the ED physician and read by the radiologist showing mild left basilar atelectasis.     COVID-19 was positive, RSV and influenza were negative.    1420: Spoke with the patient's daughter, who was informed on the risks and benefits of MAB treatment. She agreed to giving her father the treatment. The patient was given 25 mg Benadryl IV, 40 mg Solumedrol IV, 0.3 mg Epinephrine IM, 4 mg Zofran IV for nausea and 600 mg Humibid PO.    Patient tested positive for COVID-19 with symptom onset in the last 10 days and is at least 12 years old and 40 kg.  The patient still has symptoms but doesn't need hospitalization or increased oxygen requirements.  The patient does meet eligibility requirement because Patient has COPD and is over 65 years of age which makes them higher risk for complex disease and mAB was recommended. Benefits were reviewed with the patient that includes an estimated 60% decrease in hospitalization and death.  Risks were reviewed with patient which includes a reaction to the infusion, which is uncommon and would be treated at the time of the infusion if needed.  The patient does consent to receive the monoclonal antibody infusion.  The patient was educated that the monoclonal antibodies are a collection of antibodies specifically designed to target the COVID-19 virus.  It is used to help the immune system fight off COVID more quickly and make hospitalization and severe illness less likely.  There is no direct charge to the patient.  A vaccinated patient can receive this infusion without waiting.  If the patient is not yet vaccinated, they will wait 90 days from the infusion before getting vaccinated. If getting the infusion, the patient will be scheduled for an outpatient infusion to be administered.  The patient was instructed to tell the triage nurse ?they have COVID and were sent from the Hotline to get a COVID antibody infusion and are not to be checked in as a regular patient.?  The patient was given a time to arrive and the charge nurse was notified of the patient.  The patient is aware it will take about 2-3 hours including prep time and observation afterwards.    1559: Spoke with nursing home staff, who stated that he will be under constant observation and will be in isolation.    The patient was updated on his results and the plan of care. Prescription for Mucinex was provided for congestion. The patient was advised to follow up with his primary care physician, Dr. for reevaluation, and to contact their office to schedule an appointment. Return precautions are provided, and he will return here immediately with any new or worsening symptoms. The patient verbalized understanding and agreement, and was discharged home in stable condition.   On 11/16/2021 Patient presented again to the to the emergency department with chief complaint of concern for fluctuating pulse oxygenation at the outlying facility.  Per EMR there was no reported number associated with the fluctuations.  Patient does state that he feels short of breath but denies any additional symptoms.  He has had breakfast this morning but has not been drinking as much fluids as he reports he should.  He denies any fever, chest pain, nausea or vomiting.  He was seen here on 11/26/2021 where diagnosis was confirmed. CMP did not show any significant electrolyte abnormalities with an elevation of his BUN and creatinine to 66 (48) and 3 (1.7) which shows marked significant elevation.  For this acute kidney injury do believe he should be admitted for close rehydration and re-evaluation. Troponin was minimally elevated at 0.027 which could likely be because of the acute kidney injury. CBC is unremarkable with no signs of acute anemia or leukocytosis. Magnesium was within normal limits. Procalcitonin was essentially negative. The chest x-ray was reviewed by the ED physician showed no acute pneumonia. Patient to be admitted for further management of AKI on CKD 3. Patient remained stable on RA. Diuretics were on hold and Cr improved to 1.8. Patient to resume lasix on discharge but to discontinue other diuretics. SLP evaluated patient for dysphagia and recommended patient to be on pureed solid and thin liquid diet with meds crushed. PT/OT evaluated patient and recommending post acute therapy. Followed for DC planning and patient was accepted. Patient stable for DC to SNF. Needs f/u with PCP in 1 week.