Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Hypovolaemia, Leukocytosis, Malnutrition, Metabolic encephalopathy, Mitral valve incompetence
Clinical narrative: PROVIDER PROGRESS NOTE 2/7/2022 ASSESSMENT/PLAN The patient is a 69 y.o. male with history of alcohol abuse, CKD, hypertension, gout, who presents with generalized weakness, confusion, falls.    Hyponatremia: Suspect hypovolemic due to poor oral intake.  Patient received 1L LR in the emergency department.  Sodium 120 on admission. o Nephrology consult requested and appreciate input o Sodium level is now normal   AKI on CKD 3: Likely prerenal.  Baseline creatinine 2.0.  Nephrologist is (Privacy). Hypokalemia o Monitor renal function, creatinine is slowly improving o Avoid nephrotoxins o Nephrology consult and greatly appreciate their input o Foley was removed on 02/05/2022 and patient has been incontinent of urine. Bladder scan and check postvoid residual if possible.  Straight catheterize as needed.   Catheter associated UTI: UA showing packed field WBC, packed field RBC.  Leukocytosis present.  Nephrology notes reports patient has been using a Foley catheter for the past 4 years, which he started on his own without urologic evaluation/consultation for urinary incontinence, and he changes it every 4 to 5 months. o Completed a 5-day course of IV ceftriaxone o Urine culture shows mixed flora   Acute alcohol withdrawal with history of cirrhosis: Last drink on evening of 1/29/22.  Reports drinking 3 ounces liquor daily.  Hepatologist is (Privacy). o CIWA protocol with Valium, thiamine, multivitamin o Patient no longer in withdrawal and CIWA protocol discontinued   Rhinitis, possible sinusitis: CT head showing complete opacification of right maxillary and sphenoid sinuses.  Previously followed in ENT clinic for rhinitis and poor sinus drainage, eventually improved with Atrovent. o Atrovent nasal spray 3 times daily   Hypertension:  o Continue PTA Coreg   Generalized weakness, falls, metabolic encephalopathy: Multifactorial due to hyponatremia, UTI, alcohol withdrawal.  Lives independently at baseline.  CT negative for bleeding. o PT/OT.  Plan for either home with home care or TCU placement.  Unfortunately, TCU placement will be challenging because of his positive Covid status. o Per RN, patient seemed somewhat more confused today.  Asking about where the nearest bar was, etc.   Depression:  o Continue PTA Abilify, trazodone, Effexor    COVID-19 infection o Patient was incidentally found to have COVID-19 on nasal swab done on admission o He is on room air and hence does not qualify for any COVID-19 directed therapies o He is vaccinated   New onset, paroxysmal atrial fibrillation -Spontaneously converted to atrial fibrillation on 2/5/2022.  No prior history. -CHA2DS2-VASc 2 (Age, hypertension) -Heart rate is controlled, continue Coreg -TSH is normal, 2D echocardiogram showed an EF of 60 to 65% and moderate MR -Was living at home previously and was falling frequently.  Plan to discharge to a TCU for short-term rehab. -Appreciate cardiology input -Patient started on anticoagulation with Eliquis -Cardiology recommends that if patient continues to be a fall risk, and ends up in an unmonitored environment, then anticoagulation should be discontinued and patient should be started on low-dose aspirin as the risks of bleeding outweigh the benefits of anticoagulation.   Malnutrition : Severe Malnutrition   Loss of Muscle Mass: Moderate Loss of Subcutaneous Fat: Mild Energy Intake: Less than or equal to 75% of estimated energy requirement for 1 month or greater Interpretation of Weight Loss: Not Reported    DVT Prophylaxis: Add heparin subcu   Universal COVID-19 Screening: SARS-CoV-2 RNA by PCR Date Value Ref Range Status 01/31/2022 SARS-CoV-2 RNA Detected (A) SARS-CoV-2 RNA Not Detected Final