Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Fatigue, Fibrin D dimer, Fluid intake reduced, Full blood count abnormal
Clinical narrative: Hospitalized (1.2.22 - 1.6.22); COVID-19 positive (1.2.22); Fully vaccinated  - moderna x2 Discharge Summary   BRIEF OVERVIEW: Admission Date: 1/2/2022 Discharge Date: 01/06/2022  Discharge Disposition: Home     DISCHARGE DIAGNOSIS: 1. Severe COVID-19 pneumonia 2. Chronic obstructive pulmonary disease 3. Hypertension 4. Hyper glycemia 2/2 steroids (resolved) 5. Hypokalemia (resolved) 6. Opioid dependence 7. Hypothyroidism 8. Anxiety and depression 9. GERD 10. Tobacco use PRESENTING PROBLEM: Shortness of breath   HOSPITAL COURSE: Patient is a 57-year-old female who was admitted on 01/02/2022 for COVID-19 pneumonia with acute hypoxia.  Patient was treated with Remdesivir, Albuterol, & Decadron.  She has been weaned off of oxygen.  Respiratory therapy evaluated today and patient did not meet criteria for needing oxygen at home.  Patient states that she feels great her lung sounds still have slight wheeze and crackles but she is on room air.  Prescribed Decadron to complete a 10 day course as well as Tessalon Perles.   Hypertensive Blood pressure consistently elevated started patient on lisinopril 5 mg daily.   Hypokalemia Patient was hypokalemic this morning at 3.1 given 40 mEq x2 and 10 mEq IV x2, repeat potassium just before discharge is 3.8.   Discussed post COVID complications, signs and symptoms , and when to return to the ER versus calling PCP. Patient and spouse were involved in this education.  Vitals are stable patient is medically clear for discharge home with spouse.     PERTINENT LABS AND STUDIES: Last CRP 23.7 and last D-dimer 570   Physical Exam at Discharge Enc Vitals BP: 147/91 Pulse: 70 Respirations: 20 Temperature: 36.3 °C Temp src: Oral SpO2: 99 % Weight: 56.6 kg Height: 152.4 cm Room air   Physical Exam Constitutional:  Frail, pleasant, appears older then stated age. No acute distress. Alert and oriented to person, place and time. Answering questions appropriately. Cardiovascular: Normal rate and regular rhythm. 2+ radial/pedal pulses bilaterally.  Pulmonary/Chest: Unlabored speech and respirations on room air. No use of accessory muscles. Lung sounds with expiratory wheeze to left upper lung, diminished lung sounds with faint crackles in all other lung fields. Abdominal: Soft. Non-distdended. Non tender. Normal bowel sounds. Musculoskeletal: Moving all four extremities spontaneously.  Steady gait throughout room. Integumentary: Warm, pink, and dry.  Neurological: No gross motor or sensory deficits.   H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN: 57-year-old female admitted for COVID-19 pneumonia.   Pneumonia secondary to COVID-19 infection Hypoxic to 87% on room air Day 5 of symptoms Plan: - supplemental oxygen, wean as able - Decadron 6 mg daily x 10 days - remdesivir loading dose and maintenance dose x 4 days - Tessalon PRN for cough - Albuterol q6h PRN for wheezing - daily CMP, CRP, D-dimer - CXR as needed with worsening respiratory status   COPD - Albuterol q4h for wheezing - continue home Symbicort twice daily - Decadron as above   GERD - Pepcid 20 mg twice daily   Tobacco abuse Daily active smoker - nicotine patches   Opioid dependence On methadone since 2010  - pending medication reconciliation, pharmacy technician to call methadone clinic in the morning to confirm dose   Hypothyroidism - continue home Synthroid 125 mcg daily   Anxiety and depression - continue home Effexor XR to 25 mg daily - Geodon 20 mg daily in place of home vraylar   Diet:  General VTE prophylaxis:  Lovenox Code status:  Full           Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 57 y.o. female who presented to the Emergency Department on 01/02/2022 with multiple symptoms including cough, congestion, headache, fatigue, decreased appetite, and decreased oral intake of food and fluids.  She reports that she has been having these symptoms the last 5 days and they have been slowly worsening.  She denies significant intake of food and fluid secondary to decreased appetite.  She denies chest pain, shortness of breath, nausea, vomiting, diarrhea.  She denies any recent known sick contacts.  She has not been vaccinated for COVID-19.  She reports that she takes no medications or inhalers at home.     In the emergency department patient was found to be hypoxic to 87% on room air, requiring 2 L oxygen via nasal cannula, otherwise normotensive with normal heart rate.  CMP revealed slightly low potassium of 3.3, CBC without leukocytosis, normal hemoglobin and platelets.  COVID-19 PCR was positive and chest x-ray showed evidence of bilateral COVID-19 pneumonia as well was small right effusion.  Of note, radiology read did show concern for potential aspiration pneumonia.  Procalcitonin was added on and was normal at 0.21, and given this in the absence of fever, vomiting, altered mental status, leukocytosis, aspiration pneumonia seems less likely so antibiotics were not started at this time.     Patient Active Problem List Diagnosis ? Nicotine abuse ? Gastroesophageal reflux disease, esophagitis presence not specified ? Depression with anxiety ? Hypothyroidism, unspecified type ? Vitamin D deficiency ? Hx of gastric bypass ? Chronic obstructive pulmonary disease, unspecified COPD type  ? Unspecified severe protein-calorie malnutrition  ? Iron deficiency anemia ? PVT (portal vein thrombosis) ? Opioid dependence on agonist therapy  ? Hypertensive disorder ? Degeneration of intervertebral disc ? Abdominal pain, right upper quadrant ? Liver lesion ? Pneumonia due to COVID-19 virus OBJECTIVE: BP 112/64  | Pulse 78  | Temp 36.9 °C (Oral)  | Resp 14  | Ht 1.524 m  | Wt 56.7 kg  | SpO2 92%  | BMI 24.41 kg/m²    Physical Exam Constitutional:      Comments: Ill-appearing, nontoxic, not diaphoretic  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal. No congestion.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Comments: Slightly diminished bibasilar air entry, no crackles.  Trace wheezing in the upper lung fields bilaterally.  No retractions, nasal flaring, conversational dyspnea Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Normal range of motion and neck supple.     Comments: No lower extremity edema or calf tenderness bilaterally  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: She is oriented to person, place, and time.