Reporte zur Charge UJ213AA

Symptomtext

Source of Information: Available medical record History of Present Illness: This is a 88y.o. female with hx of dementia (AAOx1 per records), CHF, VTE on eliquis, Factor V Leiden, HTN, GERD who presents to Hospital via EMS from Facility with a chief complaint of failure to thrive per EMS report. Pt is currently nonverbal, lethargic therefore unable to obtain history from the patient. Called family member listed in chart, to obtain further history. At baseline, pt is perky, sits outside of her room and talks to the residents. She does not ambulate and uses a wheelchair at the facility. She reports the patient was diagnosed with COVID approximately two weeks ago and is supposed to be out of isolation now. She continued to be weak and was informed that the patient had pneumonia due to aspiration and the Facility wanted to start antibiotics. She states the Facility originally informed her that she was getting better and eating, however on 1/29, she was informed that she was pocketing food which progressed significantly to complete cessation of eating/drinking. She states the facility discussed initiation of a feeding tube and the guardian declined, stating it is too risky with her being on anticoagulation. She continued to decline in regards to PO status and informed today that she will go to the ED.