Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Cerebral small vessel ischaemic disease, Chest X-ray normal, Computerised tomogram head normal, Condition aggravated, Confusional state
Clinical narrative: Hospitalized (5.19.22 - 5.22.22); COVID-19 positive (5.19.22); fully vaccinated PLUS Booster d/c summary:  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 5/19/2022 Discharge Date: May 22, 2022   Active Hospital Problems   Diagnosis Date Noted POA  Lab test positive for detection of COVID-19 virus 05/22/2022 Unknown  Generalized weakness   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Generalized weakness [R53.1] Febrile illness, acute [R50.9] Fall, initial encounter [W19.XXXA] Head injury, initial encounter [S09.90XA] Non-intractable vomiting with nausea, unspecified vomiting type [R11.2] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 66 y.o. male with pmhx of T2DM, HTN, and BPH who presented to the ED due one day hx of acute generalized weakness, dizziness/lightheadness with two associated falls and possible LOC, and N/V w/ poor appetite and oral intake.  In the ER he was found to be hypertensive, afebrile and tachycardic. Stroke protocol was initiated (although patient only had score of 1) and CT head without IV contrast, CT perfusion of the brain, and and CT angio of the head were all negative.  He was found to be positive for COVID-19 virus.  Chest x-ray with no acute cardiopulmonary process.  He has mild nonproductive cough but otherwise no respiratory symptoms.  Says he was given 1 L of normal saline and admitted to internal medicine service for further workup and evaluation. Orthostatic vitals were negative.  Neurology was consulted.  2hr EEG with no epileptiform activity.  MRI brain with no acute infarct or lesion, does note mild increased T2 FLAIR likely representing chronic small-vessel ischemia. Echo w/ slightly reduced EF 45% (was 50% previously), Otherwise no significant new findings.  He had no further episodes of dizziness/lightheadedness.  His nausea and vomiting improved and he general diet.  Suspect that his symptoms were likely caused by COVID-19 infection although he is relatively asymptomatic from a respiratory standpoint. He has no hypoxia. PT/OT rec home. Patient was prescribed p.r.n. Zofran.  He was instructed to follow up with Cardiology outpatient given slightly reduced EF on echo and history of cardiomyopathy.  Patient in agreement discharge plan and discharged in stable condition. IP CONSULT TO NEUROLOGY    INPATIENT PROCEDURES: Echo 5/21 BP 102/61  | Pulse 94  | Temp 37.4 °C (Oral)  | Resp 18  | Wt 88.8 kg  | SpO2 96%  | BMI 32.08 kg/m²    Physical Exam   Vitals and nursing note reviewed.  Constitutional:   General: He is not in acute distress.    Appearance: He is well-developed.  HENT:    Head: Normocephalic and atraumatic.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:    General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.     Comments: Hypoactive bowel sounds  Skin:   General: Skin is warm and dry.  Neurological:    Mental Status: He is alert and oriented to person, place, and time.     5/19/22 H&P:  CHIEF COMPLAINT:     Generalized weakness   ASSESSMENT / PLAN: Generalized Weakness Unspecified Cardiomyopathy Possible Syncope -Unwitnessed fall in bathroom with possible syncope in setting of lightheadedness with a second similar episode a half hour later.  --Patient has returned from baseline. Alert and oriented to time, place, and person. Normal neurological exam and patient in no acute distress -Consider cardiac/ neurologic causes of earlier symtpoms CT head without contrast shows- no acute intracranial hemorrhage CT perfusion shows- no acute infarction or hypoperfusion CT angio of the head shows- patent vasculature without stenosis -EKG image was independently reviewed showed sinus tachycardia and T wave inversions in the lateral leads -Telemetry for possible syncope of cardiac origin  -Will order echocardiogram to further assess cardiac function -Will order MRI to further r/o stroke in setting of Covid-19 infection and hypercoaguable state -Neurology consult for possible EEG, appreciate recommendations -PT/OT evaluation -Continue home statin   Covid-19 Infection       SIRS Criteria -Positive Covid-19 test on 5/19 -SIRS critertia met: Patient febrile to 38 and tachycardic to 117 -Fever resolved after tylenol given in ED -Continuous pulse ox -Chest X ray without acute cardiopulomanry process -Patient not short of breath -Tylenol for fever as needed  -Trend CBC daily   Nausea/Vomiting    -Patient vomited multiple times in the ED -Not currently nauseous  -Electrolytes currently unconcerning, -Trend BMP daily   T2DM    -Last A1C 6.4 -Patient takes 50 units long acting nightly, 10 units short acting with breakfast, and 20 units short acting with breakfast -Will order 40 units nightly (as patient will likely eat less in hosptial) and moderate dose sliding scale -Hold home metformin   Essential Hypertension    -Suspect initial raised BP d/t anxiety -Repeat Bps stable -Continue home Coreg   Hyperlipidemia    -continue home statin   Obesity    BMI- 32.08 -Encourage healthy weight loss   DVT prophylaxis- patient low risk per risk assessment tool. Early and progressive ambulation   Code Status- full per discussion with patient HISTORY OF PRESENT ILLNESS: Patient is a 66 y.o. male with pmhx of T2DM, HTN, and BPH  who presents today with weakness x 1 day. Patient was eating dinner with his family today and fell in the bathroom shortly after. Before falling he briefy felt "light-headed" and weak. The fall was unwitnessed and patient is not sure if he lost consiousness of not but states he did not hit his head. States he was able to pull himself up on the bars that he has on  Patient was found confused and slow speech and was placed in chair which he subsduqently fell out of. Patient states his family told him about slurred speech but he does not endorse it. Patient states the second episode where he felt light headed and "fell" out of the chair was    Patient also felt lightheaded and vomitied several times today while in the ER. The vomit was nonbilious and non bloody and patietn is not currently nauseous. Patient states this feeling of lightheadedness was very similar to previous episodes in the house. Patient had returned to baseline and was not nauseous during my assessment. States he was concerned about going home to take care of wife who is in a wheelchair and has multiple health issues that he cares for.   Patient denies vertigo, headaches, chills, shortness of breath, palpitations, chest pain, facial droop, unilateral weakness, numbness/ tingling, and radiculopathy.   Patient arrived to the ED hypertensive, febrile, and tachycardic on room air. Stroke protocol was initiated (although patient only had score of 1) and CT head without IV contrast, CT perfusion of the brain, and and CT angio of the head were all negative. EKG was independently reviewed and showed sinus tachycardia with T wave changes possibly related to ischemia in lateral leads Viral panel was completed and patient was noted to be positive for Covid-19. A chest x-ray was negative for any acute cardiopulmonary process. Due to fever and tachycardia patient was started on IV fluid bolus and given tylenol which brought the fever down. Patient was admitted to observation for generalized weakness and the hospitalist team was contacted for further medical managment   Review of Systems Constitutional:  Positive for activity change and fever. Negative for chills and unexpected weight change.  HENT: Positive for hearing loss (Hearing Aids). Negative for congestion and rhinorrhea.  Eyes: Negative for itching and visual disturbance.  Cardiovascular:  Negative for chest pain and palpitations.  Gastrointestinal:  Positive for nausea, vomiting and abdominal pain. Negative for constipation, diarrhea and rectal bleeding.  Genitourinary:  Negative for frequency and hematuria.  Musculoskeletal:  Positive for falls. Negative for neck pain, back pain, muscle pain, gait problem and edema.  Neurological:  Positive for light-headedness, numbness/tingling and weakness. Negative for headaches and seizures.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for hallucinations.  Skin:  Negative for color changeOBJECTIVE: BP 132/79  | Pulse 105  | Temp 100.8 °F (38.2 °C) (Rectal)  | Resp 17  | Wt 88.8 kg (195 lb 12.3 oz)  | SpO2 94%  | BMI 32.08 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is obese.  HENT:     Head: Normocephalic and atraumatic.     Comments: No lesions noted on scalp Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Abdomen is flat. There is no distension.     Comments: Abdomen soft and nontender to palpation in all four quadrants  Musculoskeletal:        General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion. No rigidity.     Right lower leg: No edema.     Left lower leg: No edema.     Comments: Back nontender to palpation   Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No erythema.  Neurological:     Mental Status: He is alert.     Comments: Patient is alert and oriented to time place and person Cranial nerves 2-12 grossly intact Strength 5/5 in upper extremity and lower extremity Sensation intact in upper and lower extremity Cerebellar function intact  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.  2