Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Pyrexia, Red blood cell count normal, Red blood cell nucleated morphology, Red cell distribution width normal, Respiratory symptom
Clinical narrative: Hospitalized (1.11.22 - 1.14.22); COVID-19 positive (1.7.22); Fully vaccinated -moderna x2 d/c summary: Discharge Summary General Medicine  BRIEF OVERVIEW: Admission Date: 1/11/2022 Discharge Date: Jan 14, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 01/11/2022 Yes ? Sleep apnea   Clinically Undetermined ? Hypertension   Clinically Undetermined ? Hypokalemia   Yes ? Thrombocytopenia    Yes ? Mild persistent asthma   Clinically Undetermined ? GERD (gastroesophageal reflux disease) 11/20/2013 Yes   Resolved Hospital Problems No resolved problems to display.    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Hiatal hernia 11/20/2013 Unknown ? Asthma 03/12/2009 Unknown ? History of Histoplasmosis Pneumonia 03/12/2009 Unknown     Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:  Patient has been prescribed prednisone 40 mg for the next 7 days and has been sent home with supplemental oxygen.  He has been advised to contact his primary care provider in the next few days to ensure follow-up for re-evaluation.    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypokalemia [E87.6] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: 59-year-old male with a past medical history significant for mild persistent asthma as well as obesity who presents to complaints of worsening shortness of breath.  Of note, patient's symptoms began approximately 01/03/2022.   Patient required 2 L of oxygen on arrival to the emergency department.  He was started on dexamethasone as well as remdesivir and admitted to the hospital for further evaluation and treatment.   Patient was switched to prednisone at 40 mg due to wheezing on physical exam the setting of his known asthma and he was able to maintain adequate oxygen saturation on 2 L of oxygen early on in his hospital course.  Although his inflammatory markers began to trend down, he did go up on oxygen requirements requiring 3 L of oxygen but did have some improvement in his symptoms.   While maintaining and net negative fluid balance, the patient is continued on supplemental oxygen and his oxygen saturation remained stable.  As his inflammatory markers are trending down and he was feeling better on a stable mild oxygen, he was evaluated for home oxygen needs.  Patient was found to benefit from supplemental oxygen but thought to be appropriate for discharge to home on 01/14/2022.  Of note, patient did present with a mild thrombocytopenia with no evidence of bleeding.  By the time of discharge his platelet count had increased from 96-168.   CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:   BP 141/83  | Pulse 84  | Temp 36.9 °C (Oral)  | Resp 16  | Ht 1.905 m  | Wt 112.9 kg  | SpO2 93%  | BMI 31.11 kg/m²    Physical Exam General:  Obese, no acute distress Respiratory:  Clear to auscultation bilaterally, no wheezes, no use of accessory respiratory muscles  H&P:   CHIEF COMPLAINT: Pneumonia due to COVID-19 virus     Assessment/Plan    ASSESSMENT / PLAN: * Pneumonia due to COVID-19 virus Assessment & Plan Symptom onset: 1/3/2022 Isolation: Severe Respiratory, if improved/afebrile antipyretics consider deescalation on 1/13/2022 Vaccination Status: x2 dose  Continue supplemental O2, Titrate/wean to maintain SpO2>92% currently at 2 l nc  Continue Dexamethasone 1/10 Continue Remdesivir 1/5 Encourage Self Prone, IS, deep breathing and ambulation as tolerated  Symptomatic Treatment: Anti Tussives, Anti Emetics, Analgesics VTE PPx: Lovenox 40mg SQ q24 Daily CBC, CMP, CRP, D-Dimer Monitor I/O, daily weight, creatinine Maintain net neutral to negative fluid balance q24 Code Status: full      Mild persistent asthma Assessment & Plan Stable , no active wheeze Continue mdi per covid protocol    Thrombocytopenia  Assessment & Plan No alcohol use likely due to acute illness  Monitor daily    Hypokalemia Assessment & Plan Likely due to hctz  Supplemented monitor for daily needs    Hypertension Assessment & Plan Stable continuing lisinopril hctz      Sleep apnea Assessment & Plan Continue home cpap Continuous pulse ox monitoring    GERD (gastroesophageal reflux disease) Assessment & Plan Continue ppi             Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 59 y.o. male who presents today with sob and cough . pmh as noted below with osa, hx spontaneous ptx , htn . Onset uri ss myalgias 8 -10 days ago . Ss progressed to cough mostly non productive of sputum. Notes low grade fever and chills . Obtained home pulse ox with measured desaturations to mid 80's . Today with associated increased sob primarily with activity . Notes poor appetite and decreased po intake . No loss of taste or smell . No co n,v no diarrhea or dysuria. No melena or hematochezia . No dizziness or light headedness . He is vaccinated with x2 doses , has not received booster .    In ed tested positive for covid with cxr findings of multifocal infiltrate . Potassium low at 3.1 and supplemented . nml wbc count , plt level low at 96 . Was given decadron and oxygen .    Patient Active Problem List Diagnosis ? Asthma ? History of Histoplasmosis Pneumonia ? Hiatal hernia ? GERD (gastroesophageal reflux disease) ? Pneumonia due to COVID-19 virus ? Sleep apnea ? Hypertension ? Hypokalemia ? Thrombocytopenia (HCC) ? Mild persistent asthma Review of Systems Constitutional:  Positive for activity change, appetite change and fatigue. Negative for chills, diaphoresis and fever.  HENT: Negative for ear pain, tinnitus, congestion, rhinorrhea, sore throat and trouble swallowing.  Eyes: Negative for pain, redness and visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing, chest tightness and sputum production.   Cardiovascular:  Negative for chest pain, palpitations, orthopnea, leg swelling and PND.  Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea, rectal bleeding, blood in stool and trouble swallowing.  Genitourinary:  Negative for difficulty urinating, dysuria, frequency, hematuria and flank pain.  Musculoskeletal:  Positive for muscle pain. Negative for neck pain, back pain, joint pain and joint swelling.  Neurological:  Negative for headaches, dizziness, numbness/tingling and weakness.  Endo/Heme/Allergy:  Negative for adenopathy and easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for rash and wound.          Objective    OBJECTIVE: BP 128/74  | Pulse 88  | Temp 37.3 °C (Oral)  | Resp 20  | Ht 1.905 m  | Wt 112.9 kg  | SpO2 95%  | BMI 31.11 kg/m²    Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No tenderness or deformity.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Judgment: Judgment normal.