Age: 92.0
Sex: F
Vaccine: COVID19
Symptoms: Bacterial test positive, Basophil count decreased, Basophil percentage decreased, Bilirubin conjugated normal, Bilirubin urine
Clinical narrative: Discharge Summary Date of Service Jun-10-2022 0653  Date of Admission Admit Date: Jun-08-2022  Date of Discharge Date of discharge Jun-10-2022  Allergies No Known Allergies  Chief Complaint N/V/Abd pain  Final Diagnoses Acute COVID-19  Intractable nausea and vomiting  Procedure(s) Performed None  Lab Results Jun-10-2022 0730 Jun-09-2022 0420 Hematology WBC  5.1RBC  4.27HGB  12.7HCT  38.1MCV  89.2MCH  29.7MCHC  33.3RDW  13.8RDWSD  45.1PLT  231MPV  10.0AUTONEU%  75.7AUTOLYM%  16.2AUTOMON%  7.5AUTOEOS%  0.2AUTOBAS%  0.2AUTONEU#  3.8AUTOLYM#  0.8AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.01IG%  0.2 Jun-09-2022 0420 Coagulation D-DIMER  0.47 Jun-09-2022 0420 Chemistry GLUCOSE  128BUN  16CREAT  0.9MDRD GFR  58NA  140K  3.7CL  104CALCIUM  8.0CO2  28.4OSMO  282.2ANION GP  11.3BUN/CRE  17.8LDH  181CRP  7.60FERRITIN  315MAGNESIU  1.9 Jun-08-2022 0940 Coagulation D-DIMER  0.75 Jun-08-2022 0940 Chemistry ALK PHOS  98AST  21ALT  12AST/ALT  1.8TL PROT  6.0ALBUMIN  2.9TBILI  0.7DBILI  0.3LDH  201CRP  6.40FERRITIN  258DBILI  0.3 Jun-08-2022 0435 Hematology WBC  6.0RBC  4.07HGB  12.2HCT  36.5MCV  89.7MCH  30.0MCHC  33.4RDW  14.0RDWSD  45.4PLT  228MPV  9.6AUTONEU%  70.6AUTOLYM%  19.1AUTOMON%  9.5AUTOEOS%  0.2AUTOBAS%  0.3AUTONEU#  4.3AUTOLYM#  1.2AUTOMON#  0.6AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0IG#  0.02IG%  0.3 Jun-08-2022 0435 Chemistry GLUCOSE  103BUN  8CREAT  0.8MDRD GFR  67NA  140K  3.6CL  105CALCIUM  7.7CO2  29.1OSMO  278.0ANION GP  9.5BUN/CRE  10.0 Jun-07-2022 2000 Urinalysis Department SPECGRAV  1.015U-PH  6.5LEUCOCYT  NegativeNITRITES  NegativePROTEIN  30GLUCOSE  NegativeKETONES  15UROBILIN  2.0BILRUBIN  NegativeBLOOD  Trace-IntactCOLOR  Lt. YellowCLARITY  Sl CloudyMICROSCP  YCULTURE  NWBC  3-5RBC  0-2SQUAM EP  NoneBACTERIA  3+MUCUS  None Jun-07-2022 1850 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  YCVDEMPHC  NCVDSYMP  YCVDSYMDT  06052022CVDHOSP  NCVDICU  NCVDRESID  NCVDPREG  N Jun-07-2022 1849 Hematology WBC  10.1RBC  4.45HGB  13.2HCT  39.8MCV  89.4MCH  29.7MCHC  33.2RDW  13.9RDWSD  45.1PLT  276MPV  10.4AUTONEU%  80.1AUTOLYM%  11.0AUTOMON%  8.1AUTOEOS%  0.1AUTOBAS%  0.4AUTONEU#  8.1AUTOLYM#  1.1AUTOMON#  0.8AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.03IG%  0.3 Jun-07-2022 1849 Chemistry GLUCOSE  119BUN  10CREAT  0.7MDRD GFR  78NA  136K  3.7CL  99CALCIUM  8.3ALK PHOS  120CO2  26.2AST  16ALT  8AST/ALT  2.0TL PROT  6.9ALBUMIN  3.6TBILI  0.8OSMO  272.1ANION GP  14.5BUN/CRE  14.3CRP  5.70LACTATE  1.30TROPI-HS  17 Imaging Results CXR: On discharge: mild cardiomegaly, no consolidations. No acute cardiopulmonary findings.  Functional Status* Activity of daily living - Needs assistance  Mental Status* Normal Cognition  Social History tobacco use Former Smoker, 1 Packs Per Day, Smoking Cessation Not Applicable  alcohol use No Known Use  drug use No Known Use  marital status Widowed  Health Concerns Acute COVID-19  Intractable nausea and vomiting  Former Smoker, 1 Packs Per Day  Father Deceased Carcinoma of prostate  Mother Deceased Heart disease  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Jun-10-2022 0520 T 97.7 HR 78 RR 17 BP       153  / 90 O2Sat 93 Jun-09-2022 2210 T 98.0 HR 61 RR 17 BP   143 / 74 O2Sat 95 PHYSICAL EXAM CONSTITUTIONAL:  Patient appears comfortable and in no acute distress, resting in PCU on 2LNCO2 finishing breakfast  EYES: Non injected sclera.  ENT: Normal hearing. Moist mucus membranes.  CARDIOVASCULAR:  Heart has irregularly irregular rhythm with rate control without murmur, pulses are 2/2 in the upper extremities, no edema noted in the LE, no jugular venous distension  RESPIRATORY:  Auscultation reveals breath sounds distant and shallow to auscultation throughout with faint rhonchi, respiratory effort is non-labored  GASTROINTESTINAL:  Abdomen is soft, nontender, and mildly distended. Bowel sounds present and normoactive  SKIN:  No wounds or rashes appreciated on the head, arms, or legs  NEUROLOGICAL:  No gross neurological deficits noted, sensation is grossly intact  PSYCHIATRIC:  Patient is alert and oriented to person, place, time, and event. Patient's mood is euthymic, affect is appropriate. RASS of 0.  Hospital Course Patient is a 93 year old female with history of HTN and HFpEF that presented to Facility 6/7/22 for generalized malaise, abdominal pain, nausea, shortness of breath. Found to be COVID + in a vaccinated and boosted patient with likely exposure 6/5/22 with church attendance and she lives at senior living.       Her course of admission has been uneventful. Echo shows continued HFpEF with small pleural and pericardio effusions. Initially she required a few L/min of supplemental oxygen to maintain saturations which resolved after diuresis. The abdominal pain is presumed to be 2/2 to COVID GI upset and is also much improved.   Discharge today to return to Senior living. Now with anticoagulation for a fib stroke prophylaxis. Follow up with PCP in 1 week.  Condition at Discharge Stable  Discharge Disposition Discharge to home  Plan Assessment: - Community acquired viral pneumonia secondary to COVID-19 - COVID-19 secondary to sars-cov2, COVID-gram 113 points for 17.7% risk of severe illness - Acute hypoxic respiratory failure, requiring 2 L supplemental oxygen - New onset atrial fibrillation, unknown chronicity, CHAD-vasc 5 points - Essential hypertension with LVH - Chronic heart failure with preserved ejection fraction, with mild acute decompensation, grade III diastolic dysfunction - Reported history of frequent urinary tract infections, no recent abx  Plan: Discharge to home today in stable condition.  PPI for GI prophylaxis with recent few days of steroids and now anticoagulation. May be able to DC PPI in 30-60 days.  I would recommend SGLT2i for HFpEF but she has history of recurrent UTIs and those would likely worsen. Ordered PRN lasix for 2-3 pound weight gain. Daily weights at home.  Mucinex PRN for cough.  Follow up with PCP in 1 week.  Primary Care Provider DO  Electronically signed by DO RESIDENT on Jun-10-2022 0827 I have seen and examined the patient on the day discharge agree with the discharge summary as documented by Dr., PGY-3. Dr., PGY-3 and I have discussed the physical exam findings and the plan for discharge today. At the time of my evaluation this morning the patient is awake and alert and currently on room air with an SpO2 of 94%. She is denying significant shortness of breath and denies cough or sputum production. Her and I have discussed her new medication which includes the anticoagulant and the pantoprazole for GI prophylaxis given her increased risk of bleeding Discharge medications include the following; Apixaban 5 mg twice daily Furosemide 40 mg daily as needed for weight gain of 3 lb in greater than 24 hours Guaifenesin ER 600 mg twice daily for cough Pantoprazole 40 mg 30 minutes before breakfast daily She is to continue her usual home medications of; Amlodipine 5 mg, 1.5 tablets daily Carvedilol 25 mg twice daily Gabapentin 100 mg, 2 capsules twice daily Losartan 100 mg daily  A total of 23 minutes has been spent in the discharge of this patient including the time spent evaluating her this morning in discussing her discharge medications, discussing medication reconciliation with the resident, and documenting this note. Electronically signed by DO on Jun-10-2022 1219