Age: 85.0
Sex: F
Vaccine: COVID19, COVID19, FLUA4
Symptoms: Loss of personal independence in daily activities, Malaise, Metabolic function test abnormal, Myalgia, Pallor
Clinical narrative: **Of note- pt present to ED & admitted on 5/31/22.  Currently still inpt there Hospitalized (5.24.22 - 5.25.22); COVID-19 positive (5.24.22); fully vaccinated PLUS Booster - moderna x3 ATTESTATION:   Patient personally seen and interviewed on  05/25/2022 . Case was discussed in detail with PA-C. I personally reviewed the history of present illness, pertinent medical history, review of systems, and medications. I repeated pertinent portions of the examination and reviewed the relevant imaging and laboratory data. Agree with documentation with the following additions or corrections:     Brief exam: Well appearing appears stated age in no distress sitting up at side of bed on phone satting 96% on 2L NC without conversational dyspnea lungs good flow without wheeze or crackles HR irregular with normal rate no leg edema     MDM: Feels much improved and would very much like to go home. Established with transitions to home program. Discussed anticipated exertional dyspnea and need for oxygen sat monitoring at home, warning signs which should prompt discussion with HCP / presentation to ED. Okay to continue steroids while requiring supplemental oxygen above baseline.   BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 5/24/2022 Discharge Date: May 25, 2022  Active Hospital Problems   Diagnosis Date Noted POA ? COVID 05/24/2022 Yes  Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Atrial fibrillation with RVR (HCC) 05/24/2022 05/25/2022 Unknown  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Atrial fibrillation with RVR (HCC) [I48.91] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: Pt. is an 85 year old female with PMH of HTN, permanent afib on eliquis, COPD baseline 2L nocturnal requirement. Pt. presented to the ED with SOB and admitted to the hospital. Labs show COVID positive for which she reports her husband at home had a known COVID infection. Upon presentation she was also found to by tachycardic with EKG showing A-fib. IV cardizem was given and HR remained controlled on her home oral cardizem throughout the rest of her stay. Patient did require 2L supplemental O2 throughout her stay, but her SOB resolved with decadron. Patient has home oxygen and will continue with 2L supplemental O2 and complete a ten day course of decadron. She will follow up with her PCP outpatient. PT/OT recommended home with home PT. She is discharging in improved and stable condition.  INPATIENT PROCEDURES:   BP 115/67  | Pulse 89  | Temp 36.7 °C (Oral)  | Resp 20  | Ht 1.549 m  | Wt 68.9 kg  | SpO2 93%  | BMI 28.70 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is not diaphoretic.  HENT:     Head: Atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm and dry.     Findings: No erythema.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood normal.  H&P: CHIEF COMPLAINT:     COVID ASSESSMENT / PLAN: COVID-19 pneumonia -positive test 5/24/22 -decadron, plan 10-day course or until discharged -dvt px; apixaban --deferred remdesivir today given multifactorial dyspnea, consideration for remdesivir if does not show improvement tomorrow Inpatient > 2 midnight stay given her dyspnea, felt to be multifactorial with covid-19 infection, RVR, and fluid administration in setting of mitral stenosis/poor lung reserve from COPD, high work of breathing, high risk of respiratory decompensation if discharged  Permanent atrial fibrillation w/RVR -in setting of dyspnea, albuterol use, covid infection -IV cardizem trial, treat underlying cause, telemetry, replete lytes K/Mag, monitor daily -continue PO cardizem long acting and metoprolol bid  Moderate mitral stenosis -at risk for right-sided heart failure, caution with fluids  COPD Chronic respiratory insufficiency - 2L baseline -not in acute exacerbation -bronchodilators as needed  HTN -resume home orals  Visual impairment -noted  Diet: low sodium dvt px; apixaban Code: DNR/DNI, discussed upon admission. "Let me go." Subjective   HISTORY OF PRESENT ILLNESS: Patient is a 85 y.o. female who presents today with shortness of breath. PMH includes HTN, permanent afib on eliquis, COPD baseline 2L nocturnal requirement on symbicort and prn albuterol. History supplemented by daughter at bedside. Patient's husband recently diagnosed with COVID. Patient started feeling ill 2-3 days prior to admission, with headache (since resolved), myalgias (improving) and shortness of breath. Shortness of breath only mildly improving with rescue/albuterol inhaler so she presents to the hospital today. Upon arrival today noted to be in RVR, rate in 150-160's, and requring 2L O2. CXR noted, questionable left basilar infiltrate at this time. She was given 1L NS and IV cardizem, being admitted for further management. HR improved somewhat after cardizen to 120-130's. She states she takes her home meds like 'clockwork' at 6am and 6pm.  Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for chills, diaphoresis and fever.  HENT: Negative for congestion, rhinorrhea and sneezing.  Eyes: Negative for light sensitivity and visual disturbance.  Respiratory:  Positive for cough. Negative for wheezing and sputum production.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea, claudication and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation, diarrhea and fecal incontinence.  Genitourinary:  Negative for difficulty urinating, urinary incontinence and dysuria.  Musculoskeletal:  Positive for joint pain and muscle pain. Negative for back pain, joint swelling and gait problem.  Neurological:  Negative for headaches, dizziness and light-headedness.  Endo/Heme/Allergy:  Negative for adenopathy.  Psychiatric/Behavioral:  Negative for depression, suicidal ideas, anxiety, hyperactivity and behavioral problems.  Skin:  Negative for itching.  OBJECTIVE: BP 120/87  | Pulse 121  | Temp 37.5 °C (Oral)  | Resp 20  | SpO2 94%    Physical Exam   Constitutional:      General: She is not in acute distress.    Appearance: She is ill-appearing. She is not toxic-appearing or diaphoretic.  HENT:    Head: Normocephalic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:    General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.  Cardiovascular: Rate and Rhythm: Tachycardia present. Rhythm irregular.  Pulmonary:    Breath sounds: No wheezing or rales.     Comments: +belly breathing,. Accessory muscle use, diminished air exchange throughout Abdominal:    General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:    Right lower leg: No edema.     Left lower leg: No edema.  Skin:   General: Skin is warm.  Neurological:  Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:       Mood and Affect: Mood normal.