Reporte zur Charge UJ453AA

Symptomtext

BRIEF OVERVIEW: Admission Date: 8/29/2023 Discharge Date: 9/3/2023 Discharge Disposition: home health care svc DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] COVID-19 [U07.1] HOSPITAL COURSE: Patient is a 80y/o male with a past medical history of BH. CAD, dilantin toxicity, epilepsy, dilantin toxicity, neuropathy, and sleep apnea who presented for increasing weakness. Patients symptoms began 3 days prior to admission with increasing weakness and confusion, intermittent fevers, balance issues, and a fall without LOC or head injury. Patient additionally began to develop a cough prior to presentation to the ED. With patient' s change from baseline, family called EMS to bring patient in. Upon evaluation, patient was put on 2L of oxygen on the way to the ED. Patient did not wear oxygen at baseline. In the Emergency Department, patient presented with a fever of 101.8, tachypnea, and SpO2 at 91% on 2L NC. Basic labs were ordered and revealed a mild normocytic anemia with hgb 13.2, elevated CRP of 24.1, and a mild hyponatremia 133 but were otherwise benign. 4-plex was completed and came back COVID positive. Patient was placed in respiratory precautions. EKG findings demonstrated increased PR interval from known first degree AV block, PACs, and T wave abnormality, but not significantly different from previous findings. CXR revealed mild pulmonary vascular congestion but no signs of pneumonia. D-dimer was slightly elevated at 660. Hospitalist team was contacted for further evaluation. Upon admission patient was started on remdesivir and lasix. Patient was placed in seizure precautions with his history of having seizures 1-2 times weekly. PT/OT evaluation recommending SAR, but on day 2 of admission noting that pt is improving and could potentially progress to home. Pt had a controlled fall on the morning of 9/1/2023 where he misstepped from the practice stairs, and PT was able to lower him to the ground. He sustained no injuries. On reevaluation on day of dc felt safe for dc home with HHC physical therapy . Rec on dc 2 person assist with stairs and standby assist with other ambulation. Electrolytes were monitored and repleted PRN throughout the admission. Patient clinically improved and hemodynamically stable for discharge. Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days. Patient voiced understanding was agreeable with plan of care discharge