Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Fall, Fatigue, Globulins increased, Glomerular filtration rate normal, Haematocrit decreased
Clinical narrative: Pneumonia, Sepsis  Chief Complaint   Arrived via Rescue.  Reports patient had low SpO2 and fever.  Squad arrived to find pt lethargic, 98.8 temp and 92% on room air.  History of Present Illness     81-year-old male presents to emergency department via ambulance for evaluation of lethargy, weakness, low SPO2 and a fever this morning. The patient resides at assisted living facility and staff reported that the patient was not wanting to get up this morning and was lethargic, they checked a temperature and reported that he had a fever as well as a oxygen level of 86% on room air.  They notified family of patient's symptoms.  The patient does complain of a sore throat.  Has an occasional cough.  He denies any chest pain or shortness of breath.  He has been fully vaccinated against COVID-19.  Staff did report that the patient had a fall on Saturday, reported that the patient slipped out of his chair.  Fall was witnessed.  He does have a history of falls.  Family was notified.  Family reports that the patient was at his baseline yesterday.  The patient is anticoagulated on Eliquis due to atrial fibrillation.  He denies a headache or dizziness.  He denies any neck or back pain.  He denies any chest pain or shortness of breath.  He denies abdominal pain, nausea, vomiting or diarrhea. He denies any other sites of pain.  Review of Systems     Constitutional: Positive for fever, no chills, positive for weakness and fatigue  Eye: No recent visual problems  ENT: No ear pain, nasal congestion, positive sore throat  Respiratory: No shortness of breath, ocass cough, no wheezing  Cardiovascular: No Chest pain,  Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea,  Genitourinary: No dysuria, no frequency  Musculoskeletal: No back pain, neck pain  Integumentary: No rash  Neurologic: Alert & oriented X 4, no headache, no dizziness, no numbness or tingling  All systems otherwise negative/review of systems reviewed as documented in chart  Physical Exam  Vitals & Measurements  T: 37.1  °C (Oral)  HR: 88(Peripheral)  HR: 87(Monitored)  RR: 16  BP: 127/66  SpO2: 98%  HT: 186.000 cm  WT: 108.000 kg  BMI: 31.220  O2 Therapy: Room air      General: Alert and oriented, well nourished, no acute distress.  Eye: PERRL, EOMI, normal conjunctiva.  HENT: Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa.  Neck: Supple, non-tender, no lymphadenopathy.  Lungs: Faint crackles bilateral lower lobes, diminished right lower lobe, clear to auscultation bilateral upper lung fields, non-labored respiration.  Heart: Normal rate, regular rhythm, no murmur,trace-1+ pedal edema.  Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses.  Musculoskeletal: No deformity, no tenderness or swelling.  Skin: Skin is warm, dry and pink.  Neurologic: Awake, alert and oriented x 3,  no focal neuro deficits, globally weak.  Psychiatric: Cooperative, appropriate mood and affect.  Assessment/Plan      1. Pneumonia J18.9  Afebrile, non-toxic appearing. Presented to ED for lethargy, eval of hypoxia and reported fever from facility. Sp02 92% on room air.  The patient has known dementia, family reports the patient is lethargic today and is not his normal.  The patient does respond appropriately to questions.  The patient does complain of generalized weakness.  ECG shows sinus tachycardia with second-degree AV block, no ST segment elevation.  He does have crackles bilateral lower lobes, diminished right lung base.  1 view chest x-ray shows right lower lobe infiltrate.  The patient does have an elevated white blood cell count 18,000, procalcitonin normal at 0.27, CRP elevated at 4.3.  Curb 65 score is 2 points placing the patient in a moderate risk group.  Ordered levofloxacin IV for the patient.  We will closely monitor SPO2.  Current SPO2 94%.  COVID swab was negative. Plan to admit the patient for observation due to increased risk for worsening symptoms.   Orders:   SARS-CoV-2 (COVID-19) PCR (GeneXpert), Nares/Nasal Swab, Stat collect, 05/23/22 8:30:00, Stop date 05/23/22 8:30:00, Nurse collect, No, Yes, 05/23/22, Unknown, No, Yes, Not Pregnant  Urinalysis with Microscopic Standard, Urine, Stat collect, 05/23/22 7:43:00, Stop date 05/23/22 7:43:00, Nurse collect  XR Chest 1 View Portable, 05/23/22 7:43:00, Routine, 05/23/22 7:43:00, Lethargic, No, Transport Mode: Stretcher, , No, , No, Rad Type  Notified Dr of admission. Risk Statement (what is the risk to this patient if they are NOT hospitalized): Risk for worsening mental decline due to infection, risk for falls leading to injury due to weakness related to infection, risk for sepsis, risk for hypoxia leading to respiratory arrest and/or death. ADMISSION LEVEL: Medium