Reporte zur Charge 2JAZN

Symptomtext

Discharge Provider: MD Primary Care Physician at Discharge: DO Admission Date: 1/13/2023 PRESENTING PROBLEM: Compression fracture of L5 lumbar vertebra, closed, initial encounter [S32.050A] Compression fracture of L5 vertebra, initial encounter [S32.050A] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1] HOSPITAL COURSE: Patient was a 88-year-old man who presents to the hospital with COVID-19 infection causing pneumonia. He started having frequent falls. He then developed severe back pain and presented to the emergency department on 01/13. He was found to have L5 superior endplate compression fracture. He was started on Lyrica, Flexeril and oxycodone. He was awaiting rehab placement since he was in quarantine for COVID-19. On the morning of 1/18 he was found on the floor. CT head was negative. X-ray of right shoulder done secondary to pain was negative. On that day he seems slightly confused. Oxycodone was discontinued and changed to Norco. He started to require Zyprexa for confusion and agitation. Norco and Lyrica were then discontinued. The patient had another fall on 01/19. CT head was repeated and negative. CT lumbar spine repeated show worsening of the previous L5 compression fracture. He started to develop delirium. He then started to have decreased oral intake. He started complaining of throat pain and was unable to swallow. Strep swab was collected and negative. Due to continued severe pain and inability to swallow, CT neck with contrast was performed which revealed epiglottitis. I spoke with family about his poor oral intake, very low body mass index and concern for failure to thrive. Patient decided to convert to comfort care measures only. He was placed on sublingual morphine and passed away peacefully with his family at bedside. Time of death 4:09 p.m. on 01/25/2023