Age: 37.0
Sex: F
Vaccine: COVID19
Symptoms: Prolonged expiration, Protein total normal, Pyrexia, Red blood cell count normal, Red cell distribution width normal
Clinical narrative: Hospitalized (12.21.21 - still admitted currently); COVID-19 positive (12.21.21); Fully vaccinated - J&J X1 dose H&P:    I saw and evaluated the patient on 12/21/2021, and I have reviewed and agree with the documented findings and plan of the resident or mid-level provider with the following additions:   38-year-old woman with no significant past medical history who presents with acute hypoxic respiratory failure due to COVID-19 pneumonia.  Patient was vaccinated with the Johnson & Johnson vaccine this spring but has not yet had a booster.  She is requiring 2 L of oxygen and overall feels quite unwell.  Chest x-ray is consistent with COVID-19 pneumonia.  She was given Decadron and remdesivir.  D-dimer is near normal, will hold off on CTA but continue checking CRP and D-dimer daily. Prior physician notes, labs, imaging reviewed.         Hide copied text  Hover for details   CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan     ASSESSMENT / PLAN: a 38-year-old female with no pertinent past medical history who is being admitted to the hospital for acute hypoxic respiratory failure secondary to COVID 19 pneumonia.   1. COVID-19 Pneumonia (vaccinated J&J) Patient has a 67 day history of rhinorrhea, congestion, dry cough, headaches, fever, dyspnea on exertion, body aches, diarrhea, and loss of smell.  Patient tested positive for COVID-19 on 12/16 and has been managing her symptoms with supportive care.  Patient was hypoxic and tachycardic upon arrival to the emergency department.  Chest x-ray in the emergency department demonstrated bilateral pulmonary infiltrates consistent with COVID 19 pneumonia.  Patient was given 1 dose of Decadron in the emergency department.     Plan - Decadron 6 mg day 1/10 - Remdesivir day 1/5 - Daily CMPs to assess liver enzyme while patient is on remdesivir - CRP and D-dimer.  If D-dimer is elevated, consider CTA of thorax to rule out pulmonary embolism.   Code: Full Code Diet: Normal Adult Diet DVT prophylaxis: Lovenox SubQ  Disposition: Admit to Internal Medicine Residency team      Subjective     HISTORY OF PRESENT ILLNESS: a 38 y.o. female with no pertinent past medical history who presents to emergency department due to a 6-7 day history of rhinorrhea, congestion, dry cough, headache, fevers, dyspnea on exertion, body aches, diarrhea, and loss of smell.  Patient states that she 1st began feeling symptoms around 12/15 and then went and got tested for COVID-19 on 12/16 due to patient having close contact with sick contact.  Patient's COVID-19 test was positive by PCR.  Patient states she had a progressive worsening of symptoms over the last week, and decided to come to the emergency room on 12/21 due to difficulty breathing.   Upon presentation to the emergency room, patient was found to be hypoxic with SpO2 of 85% on room air.  She was subsequently placed on 2 L nasal cannula with maintenance of SpO2 above 92%.  Patient was also tachycardic with heart rate at 107 upon presentation.  Her last recorded heart rate was still tachycardic at 100.  Routine labs in the emergency department demonstrated elevated liver enzymes with AST of 149 and ALT of 96.  Chest x-ray obtained in the emergency department demonstrated bilateral pulmonary infiltrates compatible with COVID-19 pneumonia.  Patient was given Decadron 6 mg in the emergency department.  She was subsequently admitted to the internal medicine residency team for management of her acute hypoxic respiratory failure secondary to COVID-19 pneumonia.    Of note, patient denies risk factors for DVT including history of blood clots, family history of blood clots, history of cancer, recent immobilization, OCP use, and tobacco use.    Patient Active Problem List Diagnosis ? Pneumonia due to COVID-19 virus   Past medical, surgical, family and social history reviewed.     Medical History Past Medical History: Diagnosis Date ? Anxiety       Past Surgical History Past Surgical History: Procedure Laterality Date ? HX BREAST AUGMENTATION   2010 ? HX CHOLECYSTECTOMY   2012 ? HX COLONOSCOPY   9/30/2021       Social History     Socioeconomic History ? Marital status: Married     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Not on file Tobacco Use ? Smoking status: Former Smoker ? Smokeless tobacco: Former User Substance and Sexual Activity ? Alcohol use: Yes     Comment: occ ? Drug use: No ? Sexual activity: Yes     Birth control/protection: I.U.D. Other Topics Concern ? Not on file Social History Narrative ? Not on file    Social Determinants of Health    Financial Resource Strain: Not on file Food Insecurity: Not on file Transportation Needs: Not on file Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Housing Stability: Not on file     Family History No family history on file.    Prescriptions Prior to Admission (Not in a hospital admission)   No Known Allergies Review of Systems Constitutional:  Positive for activity change, appetite change, chills, fatigue and fever.  HENT: Positive for congestion and rhinorrhea. Negative for sore throat and hoarse voice.  Eyes: Negative for light sensitivity and visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing and sputum production.   Cardiovascular:  Positive for chest pain (Patient admits to pleuritic chest pain). Negative for palpitations and orthopnea.  Gastrointestinal:  Positive for nausea, abdominal pain (Patient admits to abdominal pain that radiates to right back) and diarrhea. Negative for heartburn, vomiting and constipation.  Genitourinary:  Negative for difficulty urinating, urinary incontinence, dysuria, frequency, hematuria and flank pain.  Musculoskeletal:  Negative for neck pain, back pain and joint pain.  Neurological:  Positive for headaches, dizziness, light-headedness and weakness. Negative for numbness/tingling.  Skin:  Negative for itching, color change, nail changes and hair changes.          Objective     OBJECTIVE: BP 140/68  | Pulse 101  | Temp 36.9 °C (Oral)  | Resp 18  | Wt 95.8 kg  | SpO2 92%  | BMI 37.41 kg/m²    Physical Exam Constitutional:      Appearance: Normal appearance. She is normal weight.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Prolonged expiration present.     Breath sounds: Decreased air movement present. Examination of the right-lower field reveals decreased breath sounds. Examination of the left-lower field reveals decreased breath sounds. Decreased breath sounds present.  Abdominal:     General: Abdomen is flat. There is distension.     Tenderness: There is abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.     Progress note from 12/27/21: Attestation signed at 12/27/2021  2:18 PM Attending Physician Supervisory Statement:   I saw and evaluated the patient on 12/27/2021, and I have reviewed and agree with the documented findings and plan of the resident or mid-level provider with the following additions:   38-year-old woman with no significant past medical history who presents with acute hypoxic respiratory failure due to COVID-19 pneumonia.  Patient was vaccinated with the Johnson & Johnson vaccine this spring but has not yet had a booster.  She was treated with remdesivir and Decadron which was escalated to Solu-Medrol 1 milligram/kilogram per day.  CTA revealed now PE.  Her oxygen requirements peaked at high-flow nasal cannula, her oxygen requirements are improving and she is starting to feel better with normalized inflammatory markers. She was started on solumedrol 12/24, continue remdesivir.  Continue weaning oxygen as able.     Expand All Collapse All     Hide copied text  Hover for details   CHIEF COMPLAINT: Pneumonia due to COVID-19 virus   Assessment/Plan     ASSESSMENT / PLAN: a 38-year-old female with no pertinent past medical history who is being admitted to the hospital for acute hypoxic respiratory failure secondary to COVID-19 pneumonia.   #Acute hypoxic respiratory failure #COVID-19 Pneumonia (vaccinated J&J) Patient previously vaccinated with J&J vaccine. Currently 96% on 60% HFNC. Tested positive for COVID-19 on 12/16. CTA on 12/26 showed no PE and ground glass opacities which are consistent with COVID PNA.   -Reduced Solumedrol to 1mg/kg for IBW to 25mg BID -Wean O2 as able -Albuterol q6h -Gauifenesin-codeine and tessalon PRN for cough   #GERD -Continue Protonix 40mg daily -Continue sucralfate   #Insomnia -Trazadone nightly   #Anxiety -On Cymbalta   Code: Full Code Diet: Normal Adult Diet DVT prophylaxis: Lovenox SubQ      SUBJECTIVE: Patient laying comfortably in bed. She feels subjectively much improved with no major complaints. She is hoping to wean down on the oxygen today and feels hopeful to make progress. She states that she has been eating better as well the last few days. No acute events overnight and no further questions.   Review of Systems Constitutional:  Negative for chills and fever.  Respiratory:  Positive for cough (slight). Negative for shortness of breath and sputum production.   Cardiovascular:  Negative for chest pain and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Neurological:  Negative for headaches and numbness/tingling.     OBJECTIVE: BP 128/67  | Pulse 91  | Temp 36.3 °C (Oral)  | Resp 22  | Ht 1.6 m  | Wt 96 kg  | SpO2 95%  | BMI 37.49 kg/m²  FIO2 (%): 60 % Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Nose: No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: No murmur heard. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Rhonchi (bilateral lower lung field) present. No wheezing or rales.     Comments: On 65% HFNC Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No tenderness.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced.     Findings: No erythema or rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.