Age: 72.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Oxygen saturation decreased, Pyrexia, Respiratory tract congestion, SARS-CoV-2 test positive
Clinical narrative: 72-year-old female presents to the emergency room tonight complaining of cough congestion shortness of breath.  Her symptoms started 5 days ago.  She reports that 4 days ago she went to her primary care physician and was tested for COVID and was negative.  She has not improved with her symptoms in fact she has gotten more short of breath so she returned today and today she tested positive.  Due to her hypoxia she was referred to the emergency room.  The patient did receive the vaccination for COVID in March.  She has not had any treatment as an outpatient as today was the 1st day she has had a positive test.  She is a nonsmoker.  She does report having fever for the past 5 days intermittently.  She reports that her granddaughter who she has been around tested positive 5 days ago. Review of Systems   Constitutional:  [Patient denies fever, chills, sweats, and weight changes.] Eyes:  [Patient denies any visual symptoms] ENT:  [No difficulties with hearing. No symptoms of rhinitis or sore throat.] Cardiovascular:  [Patient denies any chest pain, palpitations, orthopnea, or PND.] Pulmonary:  As in HPI Gastrointestinal:  [No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia, or melena.] GU:  [No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge.] Musculoskeletal:  [No myalgias or arthralgias. No hot, swollen joints.] Neurologic:  [No headaches, no seizures. Patient denies numbness, tingling, or weakness on either side of the body. There are no visual symptoms.] Psychiatric: [Patient denies problems with mood disturbance or anxiety.] Endocrine: [No excessive urination or excessive thirst noted. No heat or cold intolerance. No weight gain or changes in skin or hair.] Dermatologic:  [Patient denies any rashes or skin changes.]  Physical Exam  Vitals & Measurements  HR: 94(Peripheral)  HR: 94(Monitored)  RR: 24  BP: 126/91  SpO2: 92%  WT: 91 kg   VITAL SIGN               LAST CHARTED          MINIMUM                 MAXIMUM            Blood Pressure        126/91 (10/01 22:30)    86/59 (10/01 22:15)    198/94 (10/01 17:45) Heart Rate                94      (10/01 22:30)      79     (10/01 18:30)     108  (10/01 22:15) Respirations             24      (10/01 22:30)      18     (10/01 16:41)     32     (10/01 18:30) Temperature            100.1   (10/01 16:41)    100.1   (10/01 16:41)    100.1  (10/01 16:41) SpO2                         92      (10/01 22:30)      81     (10/01 17:45)      99    (10/01 18:00) O2 Flow Rate           4        (10/01 18:00)        4     (10/01 18:00)       4     (10/01 18:00) Weight                      91     (10/01 16:41)      91     (10/01 16:41)     91     (10/01 16:41) HOSPITAL COURSE: A 72-year-old female, primary care patient of Dr.  presented to the emergency room with 5 days of symptoms of shortness of breath and cough.  She was mildly hypoxemic in the emergency room.  She was admitted, given dexamethasone and remdesivir.  By hospital day #2, she was feeling markedly better, and was wishing to go home.  She seemed very stable from an oxygen standpoint, did qualify for home oxygen with 2 L since she desaturated to 86% with ambulation.  This was set up and she was felt to be stable for discharge home to complete a course of oral dexamethasone.  She also had a followup scheduled the following day.  DISCHARGE DISPOSITION: CONDITION:  Stable and improved.