Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Acquired diaphragmatic eventration, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy, Aortic arteriosclerosis
Clinical narrative: Hospitalized (3.4.22 - 3.5.22); COVID-19 positive (3.4.22); fully vaccinated PLUS Booster - pfizer x3 d/c summary:Attestation with edits by DO at 3/5/2022  3:59 PM I personally examined this patient on the day of discharge.  The case was discussed with the Resident.  I have reviewed the DC Summary; it accurately reflects the hospital course and dc recommendations.     Came to ER early morning on 3/5 with fever, chills and weakness.  Temp 38.6 on arrival.  WBC 12.2.  Lactic 4.2.  Tested positive for Covid.  Received 1L NS.  Pts symptoms improved.  She was admitted by our service at 5am.  I saw pt at 11:00am and she was feeling much better, had eating a good breakfast.  We observed a few more hous and she continue to feel wall at 2:00.  She desired discharge.  Resident discussed w/ family.  Pt discharged home.    DISCHARGE SUMMARY   BRIEF OVERVIEW: Discharge Provider: DO Primary Care Provider at Discharge: DO Admission Date: 3/4/2022 Discharge Date: 3/5/2022   HOSPITAL PROBLEMS 1. COVID-19 2. Sepsis, resolved 3. Generalized Weakness 4. Type 2 Diabetes Mellitus 5. History of DVT 6. Hypertension 7. History of CAD   No changes to home medication regimen PROCEDURES/IMAING Chest X-Ray DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 83 y.o. female presenting with chills, generalized weakness.    Sepsis 2/2 COVID-19: SIRS Criteria, febrile, leukocytosis, lactic acidosis with source of infection.  Tested positive for COVID-19.  Chest x-ray negative for acute cardiopulmonary process. Urinalysis negative for UTI.  With positive COVID test, no antibiotics were initiated for sepsis.  Admitted for further evaluation and management.  Patient was not hypoxic and did not require supplemental oxygen, steroids, or antivirals (remdesevir) during hospitalization for treatment of COVID-19. Timeline of symptoms unclear.  Did discuss with patient and family that symptoms could potential worsen over the next few days, possibly requiring return to hospital.  Patient medically stable, patient desired to discharge with plan to monitor symptoms at home over next few days.    Chronic conditions: Stable throughout hospitalization.  No change to home medication regimen.    BP 119/88  | Pulse 66  | Temp 37.1 °C (Oral)  | Resp 18  | Ht 1.626 m  | Wt 62 kg  | SpO2 94%  | BMI 23.46 kg/m²    Physical Exam  General: Alert, NAD Cardiac: RRR, no murmur Pulmonary: CTA bilaterally Abdomen: Soft, NTND MSK: No peripheral edema DISCHARGE RECOMMENDATIONS: Follow up after 10 days of quarantine (ending approximately 3/14) DISCHARGE DISPOSITION: Home without services CONDITION ON DISCHARGE: Stable and improved  H&P:  History and Physical  HOSPITALIST                                            Chief complaint Chills and weakness.   Problem List Principal Problem:   COVID-19 Active Problems:   Generalized weakness   DM (diabetes mellitus) (HCC)   HTN (hypertension)   History of DVT (deep vein thrombosis) left Popliteal vein - Unprovoked -      Assessment and Plan Medical Decision Making   This is an 83 years old lady who was presented to the emergency department because of generalized weakness, chills, and fever.  Her COVID-19 PCR came back positive and the patient has elevated lactic acid and leukocytosis.  She does not have hypoxia and her chest x-ray did not show any acute cardiopulmonary process.   1. COVID-19 infection.  Present admission.  Associated with fever, chills, and generalized weakness.  The patient denied difficulty breathing, coughing, diarrhea, and vomiting.  She does not have hypoxia.  The patient is not qualified for dexamethasone or other COVID-19 treatment.  Will give symptomatic treatment including Tylenol for fever and pain.  Will give Lovenox for DVT prophylaxis.   2. Sepsis with fever, leukocytosis, and elevated lactic acid.  Present admission.  Associated with COVID-19 infection.  The patient urinalysis did not show any evidence of urine tract infection and her chest x-ray did not show any evidence of acute cardiopulmonary process.  Will follow the trend of white blood cell count and will give Tylenol for fever as needed.  Will check lactic acid there is morning.  Because of the patient COVID-19 infection, will avoid giving more IV fluid boluses.   3. Generalized weakness and physical deconditioning.  Will ask PT OT to evaluate the patient and the need for potential placement or home therapy PT/OT.   4. Diabetes mellitus type 2. Will hold all oral hypoglycemic medications.  We will put the patient on 24 hour corrective insulin.  Latest blood sugar 161.   5. History of DVT in the past.  The patient is going to be on Lovenox 40 mg subcutaneous daily.   6. Code status.  Full code.   I discussed with the patient her clinical presentation, as well as my assessment plan.  All her questions were answered.  This is a telemedicine admission, history and physical, observation status.   History of Present Illness History and physical obtained using telehealth technology with the assistance of the bedside nurse.   Patient is a 83 y.o. female  who presents to hospital with chills and weakness. The patient is known to have history of diabetes mellitus type 2, DVT, hypertension, and mitral regurgitation.  She lives alone at home and her daughter visits her between 2 and 3 times a day and check on her.  The patient is a poor historian and most of the informations about her were taken from the emergency department documentations, and bedside nursing staff.  The patient's daughter on noticed that the patient has been getting chills with generalized weakness but without documented fever at home.  No reports of abdominal pain, vomiting, diarrhea, dysuria, chest pain, no difficulty breathing.  She brought her to the emergency department for evaluation where the patient was found to have fever 38.6° C. The patient initial workup showed lactic acid 4.2, leukocytosis 12.2, and COVID-19 PCR rapid test positive.  However the patient chest x-ray did not show any acute cardiopulmonary process.  After initial IV fluid 1 L bolus in the emergency department, lactic acid decreased from 4.2 down to 2.4.  Despite the patient lack of hypoxia, as well as dyspnea and coughing, she was very weak to be discharged home which she lives by herself.  The patient is going to be admitted to the hospital for treatment, as well as potential placement.   Review of Systems Review of Systems Constitutional:  Positive for activity change (Decreased tolerance to activities.), chills, fatigue and fever.  HENT: Positive for hearing loss ( baseline of hard of hearing.) and congestion. Negative for hoarse voice.  Respiratory:  Negative for cough, wheezing and shortness of breath.   Cardiovascular:  Positive for leg swelling ( chronic bilateral lower extremity edema.  More on the left side.). Negative for chest pain.  Gastrointestinal:  Negative for vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for dysuria.  Neurological:  Negative for headaches.  Psychiatric/Behavioral:  Negative for hallucinations, hyperactivity, behavioral problems and decreased concentration.  Objective BP 157/81  | Pulse 87  | Temp 37.1 °C (Oral)  | Resp 20  | Ht 1.626 m  | Wt 62 kg  | SpO2 93%  | BMI 23.46 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is in acute distress.     Appearance: She is not ill-appearing or toxic-appearing.  HENT:     Head: Normocephalic.  Cardiovascular:     Rate and Rhythm: Regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: No respiratory distress.     Breath sounds: Rhonchi present. No wheezing.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    Coloration: Skin is not jaundiced.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Motor: Weakness (Generalized weakness.) present.     Comments: Slow mentation.  Psychiatric:        Behavior: Behavior normal. Behavior is not aggressive, hyperactive or combative.        Thought Content: Thought content normal.