Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Serum ferritin increased, Skin ulcer, Specific gravity urine normal, Sputum culture positive, Staphylococcus test positive
Clinical narrative: Date of Service Aug-01-2022 1219  Date of Admission Admit Date: Jul-28-2022  Date of Discharge Date of discharge Aug-01-2022  Allergies Demerol - Rash  Cipro PO - Not Specified  Chief Complaint Weakness  Procedure(s) Performed None  Lab Results Aug-01-2022 0515 Serology PROCALC  0.19 Aug-01-2022 0515 Hematology WBC  10.0RBC  3.89HGB  9.6HCT  31.2MCV  80.2MCH  24.7MCHC  30.8RDW  19.9RDWSD  58.1PLT  149MPV  9.2AUTONEU%  78.2AUTOLYM%  14.8AUTOMON%  3.0AUTOEOS%  1.9AUTOBAS%  0.4AUTONEU#  7.8AUTOLYM#  1.5AUTOMON#  0.3AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.3IG#  0.17IG%  1.7 Aug-01-2022 0515 Chemistry GLUCOSE  92BUN  9CREAT  0.8MDRD GFR  70NA  143K  3.4CL  107CALCIUM  8.6CO2  26.8OSMO  283.3ANION GP  12.6BUN/CRE  11.3CRP  5.40 Jul-31-2022 0520 Serology PROCALC  0.28 Jul-31-2022 0520 Hematology WBC  9.2RBC  3.98HGB  9.5HCT  31.8MCV  79.9MCH  23.9MCHC  29.9RDW  19.7RDWSD  57.6PLT  181MPV  9.9AUTONEU%  77.3AUTOLYM%  14.1AUTOMON%  4.1AUTOEOS%  2.5AUTOBAS%  0.4AUTONEU#  7.1AUTOLYM#  1.3AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.3IG#  0.15IG%  1.6 Jul-31-2022 0520 Chemistry GLUCOSE  95BUN  12CREAT  0.7MDRD GFR  82NA  141K  4.0CL  107CALCIUM  8.5CO2  25.8OSMO  280.8ANION GP  12.2BUN/CRE  17.1CRP  8.80 Jul-30-2022 0945 Microbiology C SPUT  Staphylococcus aureus Jul-30-2022 0622 Coagulation D-DIMER  0.87 Jul-30-2022 0430 Serology PROCALC  0.44 Jul-30-2022 0430 Hematology WBC  9.9RBC  4.28HGB  10.4HCT  33.8MCV  79.0MCH  24.3MCHC  30.8RDW  19.9RDWSD  56.6PLT  197MPV  10.4AUTONEU%  77.4AUTOLYM%  12.9AUTOMON%  4.7AUTOEOS%  1.8AUTOBAS%  0.3AUTONEU#  7.6AUTOLYM#  1.3AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.2NRBC%  0.0NRBC  0.0HGB/HCT  3.3IG#  0.29IG%  2.9 Jul-30-2022 0430 Chemistry GLUCOSE  95BUN  14CREAT  0.8MDRD GFR  70NA  142K  3.0CL  104CALCIUM  8.6CO2  27.1OSMO  283.4ANION GP  13.9BUN/CRE  17.5CRP  17.00 Jul-29-2022 0535 Serology PROCALC  0.28 Jul-29-2022 0535 Hematology WBC  15.8RBC  4.75HGB  11.5HCT  38.0MCV  80.0MCH  24.2MCHC  30.3RDW  20.1RDWSD  57.5PLT  227MPV  10.3AUTONEU%  80.9AUTOLYM%  9.6AUTOMON%  6.0AUTOEOS%  0.8AUTOBAS%  0.3AUTONEU#  12.8AUTOLYM#  1.5AUTOMON#  0.9AUTOBAS#  0.1AUTOEOS#  0.1NRBC%  0.0NRBC  0.0IG#  0.38IG%  2.4 Jul-29-2022 0535 Chemistry GLUCOSE  106BUN  13CREAT  0.7MDRD GFR  82NA  138K  3.5CL  103CALCIUM  8.7ALK PHOS  71CO2  26.0AST  18ALT  18AST/ALT  1.0TL PROT  6.1ALBUMIN  2.6TBILI  0.9DBILI  0.4OSMO  276.2ANION GP  12.5BUN/CRE  18.6LDH  213CRP  18.50FERRITIN  377 Jul-29-2022 0450 Serology COVIDAG  PosCVD1TEST  NCVDEMPHC  UCVDSYMP  UCVDSYMDT  UCVDHOSP  YCVDRESID  UCVDICU  YCVDPREG  U Jul-29-2022 0450 Microbiology MRSA  No methicillin resistant staphylococcus aureus isolated after one night incubation. Jul-29-2022 0445 Urinalysis Department SPECGRAV  1.025U-PH  6.0LEUCOCYT  LargeNITRITES  PositivePROTEIN  30GLUCOSE  NegativeKETONES  TraceUROBILIN  1.0BILRUBIN  NegativeBLOOD  ModerateCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  YWBC  TntcRBC  0-2SQUAM EP  0-2BACTERIA  3+MUCUS  None Jul-29-2022 0445 Microbiology C UR  After two nights of incubation Jul-28-2022 1612 Serology COVID  PosINFLUA  NegINFLUB  NegPROCALC  0.30CVD1TEST  NCVDEMPHC  NCVDSYMP  YCVDSYMDT  UCVDHOSP  UCVDICU  UCVDRESID  YCVDPREG  N Jul-28-2022 1612 Microbiology C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary)C BLD  No growth after 2 nights of incubation. Culture is being held for 5 nights incubation. (Preliminary) Jul-28-2022 1612 Hematology WBC  14.7RBC  5.11HGB  12.3HCT  40.4MCV  79.1MCH  24.1MCHC  30.4RDW  20.2RDWSD  57.5PLT  244MPV  9.5AUTONEU%  78.8AUTOLYM%  12.8AUTOMON%  5.0AUTOEOS%  0.7AUTOBAS%  0.3AUTONEU#  11.6AUTOLYM#  1.9AUTOMON#  0.7AUTOBAS#  0.1AUTOEOS#  0.1NRBC%  0.0NRBC  0.0HGB/HCT  3.3IG#  0.36IG%  2.4 Jul-28-2022 1612 Coagulation PT  11.9INR  1.1PTT  30.3 Jul-28-2022 1612 Chemistry GLUCOSE  127BUN  18CREAT  0.8MDRD GFR  70NA  139K  3.5CL  103CALCIUM  8.7CO2  28.7OSMO  281.0ANION GP  10.8BUN/CRE  22.5CRP  21.10LACTATE  1.20PROBNP  340 Imaging Results Chest x-ray 7/29/22 official read FINDINGS: Decreasing right lung base consolidation with mild residual. Left lung clear. Calcified granulomas are unchanged. The aorta is mildly tortuous and atherosclerotic. Stable heart size. IMPRESSION: 1. Decreasing right basilar consolidation with mild residual. 2. Prior granulomatous disease. MD  Chest x-ray 7/28/22 official read FINDINGS: Frontal portable chest radiograph. Right lung apex is partially obscured by patient's face/chin. Right basilar consolidation suspicious for pneumonia in the proper clinical setting. No pleural effusion or pneumothorax. Left basilar atelectasis. Antecedent granulomatous disease. The cardiomediastinal silhouette is normal for portable technique. Atherosclerotic plaque is present. The visible bony thorax is intact. IMPRESSION: Right basilar opacity suspicious for pneumonia in the proper clinical setting. Recommend follow-up to resolution. MD  Functional Status* Disability, Hearing Impaired, Difficulty using verbal communication  Mental Status* Normal Cognition  Social History tobacco use Never Smoked, Smoking Cessation No  alcohol use No Known Use  drug use No Known Use  marital status Married  Health Concerns Pneumonia  Father Deceased Myocardial infarction @ 67  Mother Deceased Complication of cutaneous surgery @ 53  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Aug-01-2022 1113 T 98.4 HR 82 RR 20 BP       176  / 70 O2Sat 95 Aug-01-2022 0647 T 98.5 HR 79 RR 20 BP       153  / 65 O2Sat 94 PHYSICAL EXAM General: Patient appears chronically ill, comfortable and in no apparent distress.  Cardiovascular: Heart has regular rate and rhythm. No murmurs, rubs or gallops. Radial pulses 2+ bilaterally. No lower extremity edema.  Respiratory: Bilateral inspiratory wheeze anteriorly. Respiratory effort is non-labored on room air.  Gastrointestinal: Abdomen is soft, nontender and nondistended. No rebound or guarding. Bowel sounds hyperactive.  Psychiatric: Patient is calm and cooperative. Affect is constricted. Judgment and insight appear intact.  Hospital Course Patient is a 73-year-old female with a history of traumatic brain injury who presented to the emergency department with general weakness on 7/28/22. She had a positive COVID antigen test. Nursing Home on 7/15/22. She had been having a persistent cough and recently had become disoriented. She required 2L NC (baseline room air) and was tachypneic and tachycardic in the ED. Cefepime and NS 1L bolus were given. The patient was admitted for acute hypoxemic respiratory failure and sepsis secondary to suspected aspiration pneumonia and/or CAUTI. Antibiotics were changed to Zosyn in order to cover aspiration pneumonia and organisms found on cultures from previous UTIs. NS was continued at 30mL/hr. Dulera, Spiriva and albuterol inhalers were started in place of the patient's home breathing treatments. Tessalon perles were added for cough. COVID test and antigen were positive on admission so she remained in COVID precautions. Blood cultures were negative. Sputum culture grew a moderate amount of MRSA, sensitive to clindamycin, Bactrim and Levaquin. Urine culture showed 30,000 cfu multiple contaminant flora. Antibiotics were changed to clindamycin on 8/1/22. At the time of discharge she was no longer requiring 2L NC continuously and was saturating mid-high 90s on 2L while sleeping. Procalcitonin remained below 0.5 and CRP declined throughout her stay.  Condition at Discharge Stable  Discharge Medications Acetaminophen-Codeine Oral Tablet 300-30 MG 60 MG ORALLY EVERY 6 HOURS AS NEEDED for MILD PAIN (1-3 ON PAIN SCALE) Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Continue taking same as home Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% Continue taking same as home Ammonium Lactate External Cream 12 % Continue taking same as home Artificial Tears Ophthalmic Solution 0.1-0.3 % Continue taking same as home Aspercreme Lidocaine External Cream 4 % Continue taking same as home Bag Balm External Ointment Continue taking same as home BENZONATATE 100 MG ORALLY 3 TIMES A DAY AS NEEDED for COUGH Bisacodyl Laxative Rectal Suppository 10 MG Continue taking same as home Bismuth Subsalicylate Oral Tablet Chewable 262 MG Continue taking same as home Calcium Carbonate Antacid Oral Tablet Chewable 500 MG Continue taking same as home Claritin Oral Tablet 10 MG 5 MG ORALLY EVERY MORNING CLINDAMYCIN HCL 600 MG ORALLY 3 TIMES A DAY Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT 2 PUF INHALATION 3 TIMES A DAY Dextromethorphan-guaiFENesin Oral Syrup 10-100 MG/5ML Continue taking same as home Docusate Sodium Oral Capsule 100 MG 100 MG ORALLY TWICE DAILY Flonase Allergy Relief Nasal Suspension 50 MCG/ACT 1 SPR NASAL ONCE A DAY Florajen Acidophilus Oral Capsule 1 CAP ORALLY ONCE A DAY Folic Acid Oral Tablet 1 MG 1 MG ORALLY EVERY MORNING Gabapentin Oral Capsule 300 MG 300 MG ORALLY ONCE A DAY Gabapentin Oral Capsule 300 MG 600 MG ORALLY TWICE DAILY guaiFENesin ER Oral Tablet Extended Release 12 Hour 600 MG 600 MG ORALLY TWICE DAILY Linzess Oral Capsule 145 MCG 145 MCG ORALLY ONCE A DAY MiraLax Oral Packet 17 GM Continue taking same as home Nystatin External Cream 100000 UNIT/GM 1 APP TOPICAL TWICE DAILY ONDANSETRON HCl INJ 4 MG / 2 ML 4 MG INTRAVENOUS PUSH OR BOLUS 3 TIMES A DAY AS NEEDED for NAUSEA/VOMITING Ondansetron HCl Injection Solution 4 MG/2ML Continue taking same as home Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 15 MG 15 MG ORALLY TWICE DAILY Pantoprazole Sodium Oral Tablet Delayed Release 40 MG 40 MG ORALLY ONCE A DAY Sertraline HCl Oral Tablet 50 MG 50 MG ORALLY ONCE A DAY SORE THROAT 1.4 % 1 SPR ORALLY EVERY 8 HOURS AS NEEDED for OTHER (SEE COMMENTS) Triamcinolone Acetonide External Cream 0.025 % Continue taking same as home Vitamin D3 Oral Capsule 125 MCG (5000 UT) 5000 IU ORALLY ONCE A DAY Zeasorb-AF External Powder 2 % Continue taking same as home Zinc Gluconate Oral Tablet 50 MG 250 MG ORALLY EVERY MORNING Discharge Disposition Transfer to skilled nursing facility.  Plan Assessments: -Sepsis secondary to aspiration pneumonia, sputum culture growing Gram positive cocci, present on admission -Bilateral sacral ulcers, stage I, present on admission -Acute hypoxemic respiratory failure secondary to aspiration pneumonia, initially requiring 2L NC continuously, improved -Acute kidney injury, AKIN stage 1, pre-renal azotemia, unknown baseline renal function, resolved -History of COVID-19 infection, positive antigen 7/15/22 -History of traumatic brain injury secondary to MVA with residual paraplegia/general paresis, dysphagia and dysarthria -Obstructive sleep apnea, per history -History of gastric ulcer -Chronic constipation, on Linzess -Obesity -Osteoarthritis -Dry eye syndrome, bilaterally -Peripheral neuropathy -Xerosis cutis -Major depressive disorder, moderate, on sertraline  Plan: The patient is hemodynamically stable and has been cleared for discharge. Clindamycin 600mg PO TID should be continued through 8/7/22 to complete a 7-day course. Supplemental oxygen 2L NC should be continued as needed to maintain SpO2 >92%. Continue Zofran 4mg IV TID PRN during antibiotic treatment. Continue home breathing treatments. Continue Mucinex and Tessalon perles as needed for cough/chest congestion. With the patient's initial COVID antigen positive on 7/15/22, she should be considered COVID day 18. The patient should remain in COVID precautions per institutional policy. She will be scheduled to follow up with her PCP Dr.  within 7 days.  Primary Care Provider