Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Capillary nail refill test, Cardiac failure congestive, Cardiac monitoring, Cardiac pacemaker insertion, Carotid artery stenosis
Clinical narrative: Hospitalized (1.3.22 - 1.10.22); COVID-19 positive (12.29.21-self reported); fully vaccinated PLUS Booster - pfizer x3 d/c summary: Discharge SummaY: Hospitalist Expand All Collapse All Discharge Summary    BRIEF OVERVIEW: Discharge Provider:  Primary Care Provider at Discharge:  Admission Date: 1/3/2022 Discharge Date: 1/10/2022      Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 01/03/2022 Yes ? Acute respiratory failure with hypoxia (HCC) 01/03/2022 Yes ? Type 2 diabetes mellitus, without long-term current use of insulin (HCC) 01/03/2022 Yes ? Class 2 obesity with body mass index (BMI) of 36.0 to 36.9 in adult 06/27/2021 Yes ? Paroxysmal atrial fibrillation (HCC) 06/26/2021 Yes ? COPD (chronic obstructive pulmonary disease) (HCC)   Yes ? Anxiety 01/17/2019 Yes ? Chronic combined systolic and diastolic congestive heart failure (HCC) 03/28/2018 Yes ? Essential hypertension   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia [R09.02] Pneumonia due to COVID-19 virus [U07.1, J12.82] COVID-19 [U07.1]   HOSPITAL COURSE:    Patient is a 72 y.o. female who presented to the emergency department with complaints of increased oxygen requirements and hemoptysis.  She has a past medical history of type 2 diabetes, proximal atrial fibrillation, anxiety, hypertension, hyperlipidemia, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, GERD, chronic combined systolic and diastolic congestive heart failure, type 2 diabetes, and obesity. Patient states that she attended a party of approximately 24 people and shortly thereafter had increased oxygen requirement starting 12/27/2021.  She states that she is fully vaccinated for COVID-19 including a booster.  At baseline, she requires 2 liters/minute via nasal cannula.  She had a COVID test on 12/29/2021 that was positive.  She states that since this time she has had increasing shortness of breath, oxygen requirement has remained elevated from baseline, and she started having hemoptysis.  In the emergency department, patient was hypertensive, tachypneic, and had  an oxygen requirement of 3 liters/minute via nasal cannula to maintain saturation greater than 90%.  BMP showed hyperglycemia.  Complete blood count was unremarkable.  CTA of the chest showed no evidence of PE and no other acute findings.  Patient has been admitted for further evaluation and management of COVID-19 pneumonia.  Over the next several days (1/3-1/5), patient had waxing and waning respiratory signs and symptoms with increasing O2 to 3-4 L. patient actually has chronic low back pain and required 2 doses of Dilaudid on hospital day 3.    OT and PT has seen the patient recommend home health care with assistance.     Patient was able to be weaned down to 2 L of oxygen which is at baseline.  She was evaluated by respiratory therapy for home oxygen needs and was found to require 2 L at rest and 3 L with ambulation.  Patient was asymptomatic on day of discharge.  She was discharged home in stable condition on oral prednisone for 5 days 40 mg daily.       CONSULTS / RECOMMENDATION: None     OBJECTIVE:   BP 143/58  | Pulse 68  | Temp 36.4 °C (Oral)  | Resp 16  | Ht 1.575 m  | Wt 90.6 kg  | SpO2 94%  | BMI 36.53 kg/m²  FIO2 (%): 32 % Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is obese. She is not ill-appearing.  HENT:     Right Ear: External ear normal.     Left Ear: External ear normal.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: She is alert. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.  H&P: CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN: * Pneumonia due to COVID-19 virus Assessment & Plan Patient states that she had increased oxygen requirement starting 12/27/2021.  At baseline, she requires 2 liters/minute via nasal cannula, currently requiring 3 liters/minute via nasal cannula.  She had a COVID test on 12/29/2021 that was positive.  She states that since this time she has had increasing shortness of breath, oxygen requirement has remained elevated from baseline, and she started having hemoptysis.  In the emergency department, patient was hypertensive, tachypneic, and had  an oxygen requirement of 3 liters/minute via nasal cannula to maintain saturation greater than 90%.  BMP showed hyperglycemia.  Complete blood count was unremarkable.  CTA of the chest showed no evidence of PE and no other acute findings. -continuous cardiac and pulse oximetry monitoring -titrate oxygen to maintain saturation greater than 90% -start  dexamethasone daily -start IV remdesivir daily -patient is not a candidate for monoclonal antibody therapy related to escalated use of supplemental oxygen -Mucinex 2 times a day -incentive spirometry and cough and deep breathe -prone positioning while asleep -a.m. labs complete blood count, CMP, CRP, and D-dimer       Paroxysmal atrial fibrillation (HCC) Assessment & Plan Stable. -continue PTA diltiazem, flecainide, and apixaban     Type 2 diabetes mellitus, without long-term current use of insulin (HCC) Assessment & Plan Last hemoglobin A1c was 6.6 on 06/27/2021.  Patient was hyperglycemic in the emergency department, blood glucose was 143. -repeat hemoglobin A1c -low-dose corrective factor insulin -hold PTA oral antidiabetic agent -diabetic liberal heart healthy diet    Chronic back pain Assessment & Plan -analgesics available for pain p.r.n.   Chronic combined systolic and diastolic congestive heart failure (HCC) Assessment & Plan Stable.  Last echocardiogram on 05/10/2021 showed LVEF of 55% with mild left ventricular hypertrophy. -continue PTA furosemide -I&O and daily weight -diabetic liberal heart healthy diet     Acute respiratory failure with hypoxia  Assessment & Plan At baseline, patient requires supplemental oxygen at a rate of 2 liters/minute via nasal cannula.  Current requirement of 3 liters/minute via nasal cannula. -continuous pulse oximetry -titrate oxygen to maintain saturation greater than 90%.   Class 2 obesity with body mass index (BMI) of 36.0 to 36.9 in adult Assessment & Plan Body mass index 36.01.  Obesity may delay healing time and can exacerbate cardiopulmonary disease. -encourage weight loss -continue to monitor     GERD (gastroesophageal reflux disease) Assessment & Plan -continue PTA Protonix   COPD (chronic obstructive pulmonary disease)  Assessment & Plan Stable -continue PTA albuterol and Trelegy inhaler (substituted as Spiriva)   Chronic respiratory failure with hypoxia  Assessment & Plan At baseline, patient requires 2 liters/minute via nasal cannula at home.  Current requirement of 3 liters/minute via nasal cannula to maintain saturation greater than 90%. -continuous pulse oximetry -titrate oxygen to maintain saturation greater than 90%   Anxiety Assessment & Plan -continue PTA alprazolam   Dyslipidemia Assessment & Plan -continue PTA atorvastatin Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 72 y.o. female who presented to the emergency department with complaints of increased oxygen requirements and hemoptysis.  She has a past medical history of type 2 diabetes, proximal atrial fibrillation, anxiety, hypertension, hyperlipidemia, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, GERD, chronic combined systolic and diastolic congestive heart failure, type 2 diabetes, and obesity. Patient states that she attended a party of approximately 24 people and shortly thereafter had increased oxygen requirement starting 12/27/2021.  She states that she is fully vaccinated for COVID-19 including a booster.  At baseline, she requires 2 liters/minute via nasal cannula, currently requiring 3 liters/minute via nasal cannula.  She had a COVID test on 12/29/2021 that was positive.  She states that since this time she has had increasing shortness of breath, oxygen requirement has remained elevated from baseline, and she started having hemoptysis.  In the emergency department, patient was hypertensive, tachypneic, and had  an oxygen requirement of 3 liters/minute via nasal cannula to maintain saturation greater than 90%.  BMP showed hyperglycemia.  Complete blood count was unremarkable.  CTA of the chest showed no evidence of PE and no other acute findings.  Patient has been admitted for further evaluation and management of COVID-19 pneumonia.     Patient Active Problem List Diagnosis ? SVT (supraventricular tachycardia)  ? Normal coronary arteries ? Multiple sclerosis  ? Lyme disease ? Lupus (systemic lupus erythematosus)  ? Essential hypertension ? Dyslipidemia ? COPD, mild  ? Aortic valve insufficiency, etiology of cardiac valve disease unspecified ? Typical atrial flutter  ? Hyperthyroidism ? Chronic diastolic congestive heart failure  ? Tachycardia induced cardiomyopathy  ? Normocytic anemia due to blood loss ? Other iron deficiency anemia ? Mitral valve disease ? Anxiety ? Chronic right hip pain ? Physical deconditioning ? Poor posture ? Muscle weakness (generalized) ? Poor balance ? Chronic respiratory failure with hypoxia  ? Left arm pain ? Prediabetes ? Sebaceous cyst ? Flank pain ? DOE (dyspnea on exertion) ? Coronary artery calcification seen on CT scan ? Stenosis of right carotid artery ? Multiple thyroid nodules ? Paroxysmal atrial fibrillation  ? COPD (chronic obstructive pulmonary disease)  ? GERD (gastroesophageal reflux disease) ? Class 2 obesity in adult ? SSS (sick sinus syndrome)  ? Cardiac pacemaker in situ ? Positive ANA (antinuclear antibody) ? Fibromyalgia ? COVID ? Pneumonia due to COVID-19 virus ? Acute respiratory failure with hypoxia   Review of Systems Constitutional:  Positive for fatigue. Negative for chills and fever.  HENT: Positive for congestion, rhinorrhea and sore throat.  Eyes: Negative.  Respiratory:  Positive for cough, shortness of breath and sputum production.   Cardiovascular:  Negative. Negative for leg swelling.  Gastrointestinal:  Positive for nausea. Negative for vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative. Negative for difficulty urinating, dysuria and hematuria.  Musculoskeletal:  Positive for back pain and joint pain. Negative for neck pain.  Neurological:  Positive for headaches, dizziness and weakness. Negative for light-headedness.  Endo/Heme/Allergy:  negative.  Psychiatric/Behavioral:  Positive for depression and anxiety.  Skin:  Negative for itching, rash and wound.          Objective    OBJECTIVE: BP 173/60  | Pulse 84  | Temp 36.3 °C (Oral)  | Resp 20  | Ht 1.575 m  | Wt 89.3 kg  | SpO2 92%  | BMI 36.01 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not ill-appearing or diaphoretic.  HENT:     Head: Normocephalic.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregular.     Pulses: Normal pulses.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Tachypnea present. No accessory muscle usage or respiratory distress.     Breath sounds: Decreased breath sounds present. No wheezing or rhonchi.  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 or signs of injury.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No erythema or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Attention and Perception: Attention normal.        Mood and Affect: Mood normal.        Speech: Speech normal.        Behavior: Behavior normal. Behavior is cooperative.        Thought Content: Thought content normal.        Cognition and Memory: Cognition normal.        Judgment: Judgment normal