Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Hypokalaemia, Hypomagnesaemia, Hypopnoea, Hypoxia
Clinical narrative: Hospitalized (12.13.21 - 12.20.21); COVID-19 positive (12.13.21); Fully vaccinated - pfizer x2  d/c summary:  Discharge Summary   Admission Date: 12/13/2021 Discharge Date: Dec 20, 2021    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 12/14/2021 Yes ? Acute respiratory failure with hypoxia 12/14/2021 Yes ? Type 2 diabetes mellitus with diabetic polyneuropathy, without long-term current use of insulin   Yes ? Hypertension associated with diabetes  10/09/2008 Yes   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Moderate episode of recurrent major depressive disorder  04/02/2019 Unknown ? Diabetic polyneuropathy associated with type 2 diabetes mellitus  08/24/2015 Unknown ? Baker's cyst 05/23/2014 Unknown ? Chest pain 09/10/2013 Unknown ? Chronic back pain 05/30/2012 Unknown ? Cystocele 04/13/2011 Unknown ? Dyslipidemia associated with type 2 diabetes mellitus 10/09/2008 Unknown     Discharge Disposition:  home health care         DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia  Hypomagnesemia  Fall from ground level  Pneumonia due to COVID-19 virus    HOSPITAL COURSE:   a 87 y.o. female that presented to the ED with Shortness of breath after a fall. Tested positive for covid 19. chest x-ray showed:  Subtle hazy infiltrates in the right upper lung zone and in the left mid lung zone consistent with COVID-19 pneumonia. X-ray right hip, lumbar spine and T-spine were without fractures. Started on decardon and remdesivir , she was also treated pulse IV Lasix , her O2 saturation improved and remained stable on 2-4L of NC , pulmonary rehab arranged for home O2 , she will need 2 L at rest and 4L with activity . Patient was discharged in stable condition .          CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:    Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 145/57  | Pulse 63  | Temp 36.9 °C (Oral)  | Resp 22  | Ht 1.499 m  | Wt 71.4 kg  | SpO2 92%  | BMI 31.79 kg/m²  FIO2 (%): 60 % Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.    12/19/21 progress note:  Date of Admission: 12/13/2021, Hospital Day: 7   ASSESSMENT/PLAN Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Hypertension associated with diabetes    Type 2 diabetes mellitus with diabetic polyneuropathy, without long-term current use of insulin    Acute respiratory failure with hypoxia        Acute hypoxic respiratory failure -  COVID 19 pneumonia Symptom onset about one week ago, positive test 12/13  She is vaccinated against COVID-19 but is due for a booster vaccination - Allergy to decadron, continue prednisone 40mg daily plan for 10 days total treatment;  - Remdesivir completed 5 days  - Mucinex, tessalon, cepacol PRN - Monitor on cont pulse ox; wean oxygen as tolerated to maintain pulse ox greater than 90% -continue to encourage prone positioning and incentive spirometry as tolerated  - lasix IV 40 mg x3 with good response    Hypokalemia / Hypomagnesemia  Replace as needed    Fall from ground level  - Due to dizziness, denies LOC or hitting head - XR right hip/pelvis, T spine and L spine negative for fracture - Reports right hip and lower back pain after fall; but currently denies pain  - PT/OT consulted recommending home with assist   Type II DM:  - holding oral DM meds.  - corrective insulin ordered     Essential hypertension:  - Continue lisinopril HCTZ and norvasc   Hyperlipidemia:  - Continue statin   Depression:  - Continue zoloft   VTE ppx: high risk due to COVID; on lovenox  Diet: diabetic liberal Code status: DNR/DNI per discussion with patient   Dispo : plan for discharge on Monday 12/20 if her O2 requirement improved or remained stable . Repeat another dose lasix this evening .   Subjective   Patient was seen and examined  No changes  She still feels that her breathing is improving  She denies any chest pain  Tolerating PO        Review of Systems Review of Systems   Physical Exam BP 154/52  | Pulse 72  | Temp 36.7 °C (Oral)  | Resp 26  | Ht 1.499 m  | Wt 71.4 kg  | SpO2 90%  | BMI 31.79 kg/m²    Intake/Output Summary (Last 24 hours) at 12/19/2021 1148 Last data filed at 12/19/2021 1121 Gross per 24 hour Intake 680 ml Output 2550 ml Net -1870 ml   Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing, toxic-appearing or diaphoretic.     Comments: Appears elderly, frail and chronically ill  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Extraocular Movements: Extraocular movements intact.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: No tachypnea, accessory muscle usage or respiratory distress.     Breath sounds: No stridor. No wheezing, rhonchi or rales.     Comments: On 3 L nasal cannula Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple. No tenderness.     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.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Behavior: Behavior is cooperative.      Current Medications Scheduled medications ? albuterol HFA  2 puff Inhalation q4h SCH ? amLODIPine  10 mg Oral Daily ? aspirin  81 mg Oral Daily ? atorvastatin  40 mg Oral Daily ? enoxaparin  40 mg Subcutaneous q24h SCH ? furosemide  40 mg Intravenous Once ? influenza vaccine quadrivalent, adjuvanted  0.5 mL Intramuscular During Hospitalization ? insulin glargine  10 Units Subcutaneous Nightly ? insulin lispro  1-25 Units Subcutaneous 5x Daily ? miconazole  1 Application Topical BID ? oxybutynin  5 mg Oral BID ? pantoprazole  40 mg Oral Daily ? potassium chloride SA  40 mEq Oral Once ? predniSONE  40 mg Oral Daily ? sertraline  100 mg Oral Daily     Infused medications   PRN medications acetaminophen **OR** acetaminophen, benzocaine-menthol, benzonatate, guaifenesin, insulin lispro **AND** insulin lispro, melatonin, naloxone, polyethylene glycol