Age: 83.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test abnormal, Lung opacity, Lymphocyte count normal, Lymphocyte percentage, Malaise
Clinical narrative: Date of Service Oct-17-2022 1049  Date of Admission Admit Date: Oct-15-2022  Date of Discharge Date of discharge Oct-17-2022 @ 1351  Allergies Oxycodone HCl - Not Specified  Chief Complaint Weakness  Final Diagnoses Acute COVID-19  Falls  Muscle weakness  Dehydration  Procedure(s) Performed None  Lab Results Oct-17-2022 1110 Point Of Care GLUSTX  64 Oct-17-2022 0745 Hematology WBC  5.5RBC  3.77HGB  12.9HCT  37.6MCV  99.7MCH  34.2MCHC  34.3RDW  13.5RDWSD  49.5PLT  219MPV  9.5AUTONEU%  43.8AUTOLYM%  31.8AUTOMON%  16.5AUTOEOS%  6.5AUTOBAS%  0.9AUTONEU#  2.4AUTOLYM#  1.8AUTOMON#  0.9AUTOBAS#  0.1AUTOEOS#  0.4NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.03IG%  0.5 Oct-17-2022 0745 Chemistry GLUCOSE  150BUN  27CREAT  1.6MDRD GFR  41NA  137K  4.1CL  104CALCIUM  8.5CO2  26.2OSMO  281.8ANION GP  10.9BUN/CRE  16.9HGBA1C  6.1MEAN GLU  140 Oct-17-2022 0553 Point Of Care GLUSTX  106 Oct-16-2022 1928 Point Of Care GLUSTX  97 Oct-16-2022 1625 Point Of Care GLUSTX  87 Oct-16-2022 1122 Point Of Care GLUSTX  112 Oct-16-2022 0543 Hematology WBC  6.9RBC  3.32HGB  11.3HCT  34.7MCV  104.5MCH  34.0MCHC  32.6RDW  13.6RDWSD  51.8PLT  181MPV  9.5AUTONEU%  44.7AUTOLYM%  29.5AUTOMON%  20.7AUTOEOS%  3.5AUTOBAS%  0.9AUTONEU#  3.1AUTOLYM#  2.0AUTOMON#  1.4AUTOBAS#  0.1AUTOEOS#  0.2NRBC%  0.0NRBC  0.0IG#  0.05IG%  0.7 Oct-16-2022 0543 Chemistry GLUCOSE  98BUN  27CREAT  1.7MDRD GFR  39NA  139K  4.2CL  106CALCIUM  8.1CO2  22.5OSMO  282.6ANION GP  14.7BUN/CRE  15.9VIT B12  238FOL  15.7 Oct-16-2022 0516 Point Of Care GLUSTX  91 Oct-15-2022 2020 Point Of Care GLUSTX  172 Oct-15-2022 1335 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Oct-15-2022 1317 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Oct-15-2022 1317 Hematology WBC  9.9RBC  3.56HGB  11.9HCT  35.2MCV  98.9MCH  33.4MCHC  33.8RDW  13.4RDWSD  48.5PLT  220MPV  9.5AUTONEU%  70.3AUTOLYM%  11.1AUTOMON%  16.4AUTOEOS%  0.9AUTOBAS%  0.6AUTONEU#  7.0AUTOLYM#  1.1AUTOMON#  1.6AUTOBAS#  0.1AUTOEOS#  0.1NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.07IG%  0.7 Oct-15-2022 1317 Chemistry GLUCOSE  145BUN  28CREAT  1.9MDRD GFR  34NA  136K  4.6CL  101CALCIUM  8.5ALK PHOS  121CO2  23.8AST  37ALT  17AST/ALT  2.2TL PROT  7.1ALBUMIN  3.2TBILI  0.4OSMO  280.0ANION GP  15.8BUN/CRE  14.7LACTATE  1.50 Oct-15-2022 1310 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  UnknownCVDEMPHC  NoCVDSYMP  YesCVDSYMDT  Day 3CVDHOSP  UnknownCVDICU  UnknownCVDRESID  NoCVDPREG  Not Pregnant Patient was given juice and lunch after his lower sugar.  Imaging Results MEDICAL CENTER IMAGING REPORT Diagnostic radiology, p.c. www.diagnosticradiologypc.com Patient Name:Date of Exam: 10/15/2022 DOB: Gender: M Medical Record Number:  Account Number:  Accession Number:  Ordering Physician: Exam Description: CH-CHEST 1V DR EXAMINATION: CH-CHEST 1V DR HISTORY: Cough, fever COMPARISON: 4/12/2018 FINDINGS: Frontal chest radiograph. Mild right basilar atelectasis. Mild retrocardiac opacity may represent atelectasis and/or airspace disease. No pneumothorax or significant pleural effusion. Heart size is mildly enlarged. Atherosclerotic plaque is noted. The visible bony thorax is intact. IMPRESSION: Mild retrocardiac opacity may represent atelectasis and/or airspace disease. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/15/2022 2:09 PM CDT  --------------------------------------------- MEDICAL CENTER IMAGING REPORT Diagnostic radiology, p.c. www.diagnosticradiologypc.com Patient Name: Date of Exam: 10/15/2022 DOB:  Gender: M Medical Record Number:  Account Number:  Accession Number:  Ordering Physician:  Exam Description: LE-KNEE 1-2V DR EXAMINATION: 1. Right knee 2 views 2. Left knee 2 views HISTORY: Bilateral knee pain after fall COMPARISON: None FINDINGS: Frontal and lateral views of both knees. The osseous structures are intact and well aligned without acute fracture or dislocation. Mild degenerative changes at both knees. No joint effusion is seen. Bone density and texture are normal. Atherosclerotic plaque is present. IMPRESSION: 1. No acute fracture or dislocation identified. 2. Mild degenerative changes. 3. Atherosclerotic vascular disease. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 10/15/2022 3:46 PM CDT    IMAGING REPORT Diagnostic radiology, p.c. www.diagnosticradiologypc.com Patient Name:  Date of Exam: 10/15/2022 DOB: 9/06/1938 Gender: M Medical Record Number:  Account Number:  Accession Number:  Ordering Physician:  Exam Description: CH-RIBS UNILATERAL DR EXAMINATION: CH-RIBS UNILATERAL DR HISTORY: Pain after fall COMPARISON: Chest radiograph from the same date and 4/12/2018 FINDINGS: No acute or displaced rib fracture. Decreased left basilar atelectasis. No focal airspace consolidation, pneumothorax, or effusion. Cardiomediastinal silhouette is unremarkable. IMPRESSION: No displaced rib fracture. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY:  DICTATED DATE AND TIME: 10/15/2022 3:44 PM CDT  Functional Status* Impaired mobility (Parkinsons, balance)  Mental Status* Normal Cognition  Social History tobacco use Former Smoker, 1 Packs Per Day, 26 yrs, Smoking Cessation Not Applicable Started at age 18, quit approximately 40 years ago.  alcohol use No Known Use  drug use No Known Use  marital status Single  general comment Lives at home alone.  Health Concerns Acute COVID-19  Falls  Muscle weakness  Dehydration  Former Smoker, 1 Packs Per Day, 26 yrs  Father Deceased Myocardial infarction @ 56  Mother Deceased Alzheimer's disease @ 85 Essential hypertension  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Oct-17-2022 0643 T 98.0 HR 66 RR 18 BP   116 /     53  O2Sat 92 Oct-17-2022 0423 T 98.0 HR 64 RR 16 BP   141 / 70 O2Sat 95 PHYSICAL EXAM CONSTITUTIONAL:  Patient appears comfortable and in no acute distress. CARDIOVASCULAR:  Heart has regular rate rhythm, pulses are 2/2 in the upper extremities, no edema noted RESPIRATORY:  Lungs clear to auscultation throughout and respiratory effort is non-labored GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive NEUROLOGICAL:  Patient is alert and generally oriented. Sensation is grossly intact PSYCHIATRIC:  Patient's mood is euthymic, affect is appropriate. RASS of 0.  Hospital Course An 84-year-old male with history of type 2 diabetes, hypertension, CKD, Parkinson's disease, CAD with past MI, and HIV that presented to the ED with complaints of general weakness and multiple falls. He was placed under observation by the internal medicine team. He was monitored over the course of 24 hours  He remained stable. His sugars were somewhat low secondary to his  PT assessed and recommended that physical therapy would be of benefit. Patient requested that nursing home care may be appropriate, however no qualifying diagnosis was found. Patient was deemed stable and will be discharged home with home health services.  Condition at Discharge Stable  Discharge Medications allopurinol 100 mg tablet Continue taking same as home amlodipine 5 mg tablet 1 TAB ORALLY ONCE A DAY aspirin 81 mg capsule 1 CAP ORALLY ONCE A DAY Basaglar KwikPen U-100 Insulin 100 unit/mL (3 mL) Insulin Pen 48 UNT SUBCUTANEOUS DAILY AT BEDTIME Biktarvy 50-200-25 mg tablet 1 TAB ORALLY ONCE A DAY carbidopa-levodopa 25-100 mg tablet 2 TAB ORALLY 4 TIMES A DAY escitalopram oxalate 20 mg tablet 1 TAB ORALLY ONCE A DAY finasteride 5 mg tablet 5 MG ORALLY DAILY AT BEDTIME Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML Continue taking same as home lisinopril 20 mg tablet 20 MG ORALLY DAILY AT BEDTIME Omega-3 Krill Oil 500-115-30-64 mg capsule 1 CAP ORALLY ONCE A DAY metoprolol succinate 100 mg Tablet, Extended Release 24 hr 1 TAB ORALLY ONCE A DAY Nitroglycerin Sublingual Tablet Sublingual 0.4 MG Continue taking same as home Praluent Pen 75 mg/mL Pen Injector Continue taking same as home pravastatin 10 mg tablet 5 MG ORALLY DAILY AT BEDTIME tamsulosin 0.4 mg capsule 2 CAP ORALLY DAILY AT BEDTIME Vitamin D3 50 mcg (2,000 unit) capsule 1 CAP ORALLY ONCE A DAY Discharge Disposition Discharge to home with home health  Plan ASSESSMENT  1. Generalized muscle weakness secondary to COVID-19 infection, dehydration, improved 2. Mild dehydration secondary to poor oral intake, nausea/vomiting 3. Acute COVID-19 infection, mild without hypoxia, vaccinated 4. Recent repeated falls secondary to generalized weakness 5. Chronic kidney disease stage G3b, Cr 1.9, baseline likely 1.5 or higher. 6. Type 2 diabetes mellitus, possibly over-controlled with reported recent Hgb A1c of 5.5 7. Essential hypertension, controlled 8. HIV positive since 1992, controlled 9. Parkinson's disease  PLAN: Patient has been deemed stable to discharge home with home health.  Patient's lab work is improving although he remains weak. He has been seen by PT who suggested he would benefit from home therapy. We will also discharge with nursing services. Patient recently lost his wife, who had multiple health problems, and is happy to have the same service provide his home care.  Patient otherwise has improved during his stay. He is to follow up with his Primary Care Physician. Of note, patient's blood sugars have  been low. He has been advised to hold his home insulin, and informed that he may only need a half dose of his long acting.  He feels comfortable managing this at home. Ensure or Glucerna, or similar were recommended to ensure adequate nutrition. He is to drink these especially on days he feels he has not had a good meal.  Primary Care Provider   Electronically signed on Oct-17-2022 1434