Age: 20.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test negative, Sinus congestion, Upper respiratory tract infection, Vomiting, Wheezing
Clinical narrative: Chief Complaint  1/4/2022 19:44 CST       Pt presents with a cough and shortness of breath for the last 2 weeks. Pt diagnosed with a URI 2 weeks ago but symptoms have persisted      History of Present Illness  This is a 20-year-old female who presents to the clinic today for complaints of increasing cough and shortness of breath over the past 2 weeks.  She was seen in the clinic 2 weeks ago and prescribed amoxicillin.  She reports no significant improvement since then.  She notes that she has been feeling feverish and chilled over the past few days.  Cough is becoming increasingly wet and she feels more fullness and tightness in her lungs as well.  Also having sinus pressure and congestion.  She does have a history of Crohn's disease for which she recently received a treatment of Stelara, which really knocks her immune system down.    Histories  Family History:   Alive and well Father Mother Crohns disease Mother HTN (hypertension)..... Father Hypercholesteremia..... Father   Procedure history:   EGD - Esophagogastroduodenoscopy on 1/19/2021 at 19 Years. Comments: 1/19/2021 10:16 CST - RN Normal EGD EGD (esophagogastroduodenoscopy) gastric outlet reduction in 2019 at 18 Years. Comments: 1/18/2021 16:09 CST - RN At Hospital Laparoscopic cholecystectomy with cholangiography on 4/3/2018 at 16 Years. EGD in the month of 9/2017 at 15 Years. colonscopy in the month of 9/2017 at 15 Years. History of tonsillectomy.  Social History          Electronic Cigarette/Vaping Assessment           Electronic Cigarette Use: Never.     Alcohol Assessment           Never     Tobacco Assessment           Never (less than 100 in lifetime) Tobacco Use:.     Substance Abuse Assessment           Never     Sexual Assessment           Identifies as female Gender Identity:. .      Health Status  Allergies:   Allergic Reactions (Selected) Severity Not Documented No known allergies- No reactions were documented.  Current medications:  (Selected)  Inpatient Medications Ordered Rocephin: 1 gm = 1 EA, 100 mL/hr, IV Piggyback, Daily SOLU-Medrol: 40 mg = 1 mL, IV Push, q8hr (scheduled) Sodium Chloride 0.9% 1,000 mL: 100 mL/hr, IV Zithromax: 500 mg = 1 EA, 250 mL/hr, IV Piggyback, Daily acetaminophen: 650 mg = 2 tab(s), Oral, q6hr (interval), PRN: Pain/Fever albuterol 2.5 mg/3 mL (0.083%) inhalation solution: 2.5 mg = 3 mL, NEB, q4hr-WA (scheduled) Documented Medications Documented Stelara 90mg/mL: 1 mL, Subcutaneous, q8wk (scheduled), 1 mL, 0 Refill(s) Trintellix 5 mg oral tablet: 5 mg = 1 tab(s), Oral, Daily, 30 tab(s), 0 Refill(s) omeprazole 20 mg oral delayed release capsule: 20 mg = 1 cap(s), Oral, Daily, 30 cap(s), 0 Refill(s) predniSONE 5 mg oral delayed release tablet: 5 mg = 1 tab(s), Oral, Daily, 5 tab(s), 0 Refill(s)  Problem list (past medical history):   All Problems (Selected) Crohn disease Confirmed Upper abdominal pain Confirmed Nausea and vomiting Confirmed,   Active Problems (3) Crohn disease  Nausea and vomiting  Upper abdominal pain      Review of Systems  Constitutional:  Fever, Chills, Fatigue.   Ear/Nose/Mouth/Throat:  Nasal congestion.   Respiratory:  Shortness of breath, Cough, Sputum production, Wheezing, No hemoptysis.   Cardiovascular:  Negative.   Gastrointestinal:  Negative.   Integumentary:  Negative.   Neurologic:  Negative.   Psychiatric:  Negative.     Physical Examination  VS/Measurements  Vital Signs  1/4/2022 20:49 CST Peripheral Pulse Rate 101 bpm  HI  Respiratory Rate 16 br/min  SpO2 100 %  Oxygen Therapy Room air 1/4/2022 20:14 CST Peripheral Pulse Rate 126 bpm  HI  Respiratory Rate 18 br/min  SpO2 99 %  Oxygen Therapy Room air 1/4/2022 19:44 CST Temperature Oral 36.6 DegC  Peripheral Pulse Rate 109 bpm  HI  Respiratory Rate 16 br/min  Systolic Blood Pressure 133 mmHg  Diastolic Blood Pressure 88 mmHg  SpO2 100 %  Oxygen Therapy Room air   , Measurements from flowsheet : Measurements  1/4/2022 19:49 CST Weight Dosing 54.430 kg 1/4/2022 19:49 CST Height/Length Dosing 162.000 cm 1/4/2022 19:44 CST Height/Length Estimated 162.000 cm  Weight Estimated 54.430 kg  Triage Ht 162 cm  Triage Weight 54.43 kg  Triage BMI 20.74 1/4/2022 19:43 CST Height 162.000 cm  Height/Length Dosing 162.000 cm  Weight 54.430 kg  Weight Dosing 54.430 kg  Body Mass Index 20.740 kg/m2  Admission Height/Length 162 cm  Admission Weight 54.43 kg  Admission Body Mass Index 20.74 kg/m2   , Temperature 36.6  (19:44) Systolic Blood Pressure 133  (19:44) Diastolic Blood Pressure 88  (19:44) Pulse 101  (20:49) SpO2 100  (20:49) Respiratory Rate 16  (20:49)  , Weight 54.43 kg 120 lb (19:49) Height 162 cm 63.78 in (19:43)    General:  Alert and oriented, No acute distress.   HENT:  Normocephalic, Tympanic membranes are clear, Oral mucosa is moist, No pharyngeal erythema.   Neck:  Supple, No lymphadenopathy.   Respiratory:  There are crackles and wheezes to auscultation in the lungs bilaterally.  She is in no acute respiratory distress..   Cardiovascular:  Normal rate, Regular rhythm, Normal peripheral perfusion, No edema.   Gastrointestinal:  Soft, Non-tender.   Integumentary:  Warm, No pallor, No rash, No visible mottling..   Neurologic:  Alert, Oriented.   Cognition and Speech:  Oriented, Speech clear and coherent.   Psychiatric:  Cooperative, Appropriate mood & affect.     Impression and Plan  Diagnosis    Lower respiratory infection (e.g., bronchitis, pneumonia, pneumonitis, pulmonitis) (ICD10-CM J22).    Rapid Covid and RSV tests are negative.  RSV was not obtained but is on the differential.  She has significant bronchitis and I suspect pneumonia.  Given her weak and immunocompromise state we will plan to admit to observation overnight.  Will initiate IV antibiotics as well as IV Solu-Medrol and albuterol treatments.  We will plan to hydrate her up with IV fluids.  Lab and chest x-ray pending.    Professional Services   ACUTE STAY ONLY:  This patient is expected to be admitted over 2 or more midnights because of the following:  [ ]  Risk Statement (what is the risk to this patient if they are NOT hospitalized):  [Patient is at risk of worsening shortness of breath and sepsis.]  ADMISSION PROFEE LEVEL:  [ 2]     Signature Line [Electronically Signed by: 01/04/2022 21:13 CST] ________________________________________ PA-C     [Verified on: 01/04/2022 21:13 CST] ________________________________________ PA-C