Age: 89.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: International normalised ratio, Intervertebral disc disorder, Magnetic resonance imaging spinal abnormal, Mobility decreased, Muscle disorder
Clinical narrative: pt in house bed SOCIAL/FUNCTIONAL ASSESSMENT:  Baseline Mental Status  Lives With Dwelling Type  MENTAL STATUS: Alert & Oriented Person, Place or Time daughter       in single level home, 2 steps to entrance     Support at Home Caregiver, family and/or social support available to assist patient at discharge: Family Member: children MSW Consult needs identified: None at this time MSW consult order placed: No    Prior Level Of Function DME Owned Patient receiving OP services (HH, Hospice, Home infusion pharmacy, etc)      some assistance with ADLs (bathing , dressing, medication management, transporting , appointments , cooking ).Does not drive (famly for transportation)  ambulatory and uses cane, FWW FWW, Cane and wheelchair  no   Agency name/contact info:     Dialysis     IP Readmission  <30 Days ? Best contact person  or DDM HD: no no   If yes, IP admission with same dx: No Name:   Relationship: daughter     Non-Facility patient?:  no Does patient fill meds at Pharmacy?: yes   ED CLINICAL REVIEW : presented with worsening R hip pain radiating down to R leg. Pt has been unable to move, no bedbound due to pain. VSS. Temp 99.6. UA shows UTI. WBC 14.6. Received tylenol, morphine, dexamethasone and IV abtx. COVID-19 Positive. 02 sat 98% on RA.  MR SPINE:       Impression   1. Heterogeneous collection within the right psoas muscle most likely represents a hematoma. Infection/abscess is less likely though difficult to exclude.   2. Tiny T2 hyperintense signal within the T10-11, L1-2, L3-4, and L5-S1 disks is most likely degenerative though discitis would be difficult to exclude if infection is suspected clinically.   3. Degenerative findings in the lumbar spine with canal and foraminal narrowing as detailed above.           -Covid test completed: Yes, Date:8/16/23   - Chart reviewed and care discussed with: patient      - Level of care recommendation: OBS per conversation with HBS   RN  8/17/2023 1:16 AM   INPATIENT/OBS CLINICAL REVIEW    8/17/23:  WBC 15.7, BUN 33, Cr 1.12, INR 1.6.  Continues on IV heparin gtt and IV abx.  Physical therapy evaluation pending.   RN  8/17/2023 2:14 PM 8/18/23:  BP 133/39, HR 40's, WBC 15.1, BUN 52, Cr 1.32.  Continues on IV abx.  Physical therapy is recommending daily PT at SNF upon d/c.  Spoke with pt's daughter, via phone regarding plan of care and d/c plan; pt's daughter acknowledged understanding and is agreeable with SNF placement upon d/c.   RN  8/18/2023 4:20 PM 8/19/23: K 5.7, Cr 1.55, BUN 64, WBC 12.8, H/H 8.8/27.8. IV Abx, VSS, RA. Plan for renal US today. Per HBS, patient not ready for discharge today.   RN  8/19/2023 10:57 AM 8/20/23:  Pt to be re-image tomorrow, and then restart coumadin on Tuesday, monitor after that.  Possible dc in 3 days.  RN@1517. 8/21/23:   Spoke to daughter and she is still agreeable for patient to go to snf when patient is stable, plan remains the same, re-image hematoma, restart coumadin and monitor.  Likely 2-3 days before patient can be dc to snf.   RN@12:18pm. 8/22/23 Patient continues on Ertrapenem IV, receives IV morphine prn for pain control. Plan to restart coumadin after imaging studies, CT abd pelvis done 8/21 at 1945, then discharge. RN  8/22/2023 11:52 AM Addendum: Spoke to HBS this afternoon--per HBS, assessed hematoma and determined will need surgery consult.  RN  8/22/2023 1:44 PM 8/23/23 Patient continues to be on Ertapenem IV abx. Per HBS, will order repeat MRI for R psoas hematoma given there is a drop in patient's Hgb (7.4). Per HBS patient needs atleast 48 hrs of stable hemoglobin before restarting anticoagulation. Per HBS not medically stable to dc home. Spoke to patient and patient's daughter (with patient's consent) for update. Still agreeable with plan for SNF when medically stable. Continues on insolation. RN  8/23/2023 11:04 AM     ANTICIPATED DISCHARGE PLAN SNF      skilled PT / has 100 skilled day s ESCRIPTION 0 Per ADMISSION(S) 1-100 DAY(S) 00% MR Per ADMISSION(S) 101-9999999 DAY(S)     Case Manager to follow up:   -MRI result -monitor for bleeding, H/H after coumadin started - need   SNF referral  Preferrence: Post Acute -Covid isolation through the 26th - PASSAR done  8/22       DME  -Recommended DME Needs: TBD   -DME Copay: No Copay      DME item      Deliver To: (Home, Hospital Room, B&C, etc)     Order date   Delivery date                    COC RNCM handout provided to patient: N/A - Pt currently under COVID precautions Best Practice Medicare Post Discharge Meal referral completed: Yes, Date: 8/17/23 MOON letter: N/A IM letter last given: Yes, Date: 8/17/23 Transitional Risk Score: Low    Anticipated Transportation for DC: Ambulance transport, Copay: No Copay     RN  8/23/2023 11:05 AM          Note Details  Author (R.N.) File Time 8/23/2023 12:06 PM Author Type REGISTERED NURSE Status Signed Last Editor (R.N.) Specialty GENERAL, OTHER Hospital Acct #  Admit Date 8/16/2023  ED to Hosp-Admission (Current) on 8/16/2023  ED to Hosp-Admission (Current) on 8/16/2023   Detailed Report  Note shared with patient Care Timeline  08/17   Admitted from ED (Observation) 0007    Admitted 0833