Reporte zur Charge 1822811032022

Symptomtext

BRIEF OVERVIEW: Admission Date: 9/4/2023 Discharge Date: 9/6/23 Discharge Disposition: home health care svc DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: AKI (acute kidney injury) [N17.9] COVID-19 [U07.1] Acute respiratory failure due to COVID-19 [U07.1, J96.00] HOSPITAL COURSE: Patient is a 67 y.o. male past medical history former smoker, COPD, currently undergoing treatment for NSCLC post LLL resection in June 2022 who presents with increased cough, fatigue and congestion. Patient lives at home with decreased outside exposure. At baseline he wears 3 L n/c upon getting up and ambulating in his garage and with increased level of activity around his house. He reports some infrequent monitoring of pulse ox in which he usually ranges from 96- 88% on RA. He reports the lowest he has observed is 85%. Patient reported he has a housemate who had gone on a trip from 8/27-8/31 and upon returning home has congestion in which was contributed to his allergies. The patient noticed later in the night and early am of 9/1, he began coughing with increased congestion. Patient reported continued increase of symptoms with decreased appetite. He denies nausea, vomiting or fever. Due to continued cough he called EMS this am because he "just couldn't take it" any longer. EMS gave patient breathing treatment enroute and continued him on 3L n/c as he was wearing at home. In the Emergency Department, patient continued to remain tachycardic and tachypneic therefore remaining on 3 L nasal cannula with an oxygen saturation of 96-98%. Laboratory testing showed mild renal insufficiency with slightly elevated creatinine of 1.42 and positive COVID testing. Other laboratory testing was unremarkable. CT angiogram thorax was completed and showed no evidence of PE, coronary artery disease, pulmonary emphysema, and stable postoperative changes of the left lower lobectomy. EKG was performed and showed sinus tachycardia with a heart rate of 125. Lactic acid was within normal. Troponin level was negative. Patient was given Tessalon capsule, dual nebs and IV fluid bolus with Decadron for treatment of hypoxic COVID. Admission to the hospitalist service was accepted for continued care and treatment. He had improvement with steroids and declined therapy evaluation. He was discharged on his home oxygen requirements in stable conditions to home.