Discharge Provider: MD Primary Care Provider: MD Admission Date: 4/4/2023 Discharge Date: 4/9/2023  PRESENTING PROBLEM: Syncope and collapse Syncope, unspecified syncope type COVID-19   HOSPITAL COURSE: Patient is an 84-year-old female with a past medical history significant for depression, bipolar disorder, psoriatic arthritis on methotrexate, hypertension, CKD 3 who presents after she had brief episode of loss of consciousness. She was on the commode have a bowel movement, was straining, remembered having lightheadedness and feeling unwell followed by loss of consciousness.  Caregiver was in the bathroom unwitnessed episode and she held patient to the floor.  There was no head injury no evidence of seizure-like activity no prolonged confusion following the episode.  Patient woke up on the floor and did not have any further issues and was back to baseline. In the emergency department found to have mild tachypnea but otherwise normal.  No hypoxia on room air.  EKG showed PVCs otherwise unremarkable.  She was found to be COVID 19 positive. She was found have mild AKI and for which she was placed on IV fluids and this did resolve.  Patient had steady decline since the death of her husband in December 2022 and has been admitted multiple times due to various issues.  She previously was on Depakote although this was discontinued for unclear reasons a while back.  She was on sertraline 50 mg daily.  Patient stated that she felt depressed but did not want any increase in her sertraline dose. Patient incidentally found to be COVID positive.  She is fully vaccinated and also had a prior COVID-19 infection 2021. She had no hypoxia or other symptoms except for cough and not felt to require any therapy for COVID-19. She remained hemodynamically stable and had no further episodes of loss of consciousness. Patient felt to have had vaso vagal episode while straining on the commode and no further workup was indicated. Patient was previously on hydrochlorothiazide and amlodipine which were recently stopped due to low blood pressures.  She was taking valsartan which was held at the time of admission due to acute kidney injury.  As renal function had normalized, she was resumed back on her valsartan with stable blood pressures. She was seen by PT and OT who initially recommended home with home health therapy. Patient's family stated that she would need 247 coverage and that was unavailable as patient is currently COVID positive and will not be able to get a caregiver until 4/11. Initial plan after discussion with patient's daughter was that patient would be discharged back to her independent living facility and that family would provide care at home. Patient's family then stated that they would not be able to help care for patient until they had private duty caregivers.  Patient was hemodynamically stable and it was explained to patient's family that she did not require any further inpatient stay and she was ready for discharge. Patient was re-evaluated by Physical therapy on 04/09 who stated that patient could discharge home with assist and that she had all her needed equipment at home.  PT stated that patient will need assistance for meals, showering and IADLs but she did not require 24/7 assist as patient was independent with mobility and able to manage toileting tasks. Family were able to arrange for care at home and patient was discharged in stable condition 04/09/2023