Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Confusional state, Cough, Culture urine, Differential white blood cell count, Dyspnoea
Clinical narrative: 2/3 rehab visit: PA - 02/03/2021 12:25 PM CST Formatting of this note might be different from the original. NURSING HOME ACUTE VISIT    6/24/1955 MD  SUBJECTIVE:  Chief Complaint  Patient presents with  ? Cough  Pt has COVID 19 and she is coughing and congestion.   This is an acute visit with pt. Status and changes discussed with staff.   Advanced directives on file.   Allergies reviewed at NH, though may not be fully updated in electronic record.   Problem List reviewed.   ROS:   Gen: Denies fever CV: Denies chest pain Resp: Denies dyspnea GI: Denies abdominal pain.  GU: Denies dysuria.  Psych: Denies depression.   OBJECTIVE:   VITALS:  Vitals:  02/03/21 1226  BP: (!) 94/54  Pulse: 79  Resp: 18  Temp: 37 °C (98.6 °F)  SpO2: 96%   PHYSICAL EXAM:   General: Alert, awake, no acute distress Skin: Intact HEENT: Grossly normal Neck: Supple Lungs: Within normal limits/clear CV: RRR Abdomen: Soft, BS active Extr: WNL Neuro: Unchanged and nonfocal  ASSESSMENT/PLAN:   Reviewed and signed orders. Recheck in 60 days.   Patient was seen today for cough.  Diagnoses and all orders for this visit:  COVID-19  Cough  CXR 2 view. Plan to start melatonin, vit D3, zinc.    Rehab nurse note: Table of Contents for Miscellaneous Notes Telephone Encounter - RN - 02/09/2021 9:30 AM CST Telephone Encounter - 02/09/2021 9:16 AM CST   Telephone Encounter - RN - 02/09/2021 9:30 AM CST Discussed with Dr. and he recommended that patient go to ER for urgent evaluation/treatment with dyspnea and low O2 levels even with supplemental oxygen.    Electronically signed by RN at 02/09/2021 9:32 AM CST   Back to top of Miscellaneous Notes Telephone Encounter - 02/09/2021 9:16 AM CST Rehab called, they stated PT was having trouble breathing and her O2 was 80 with oxygen. They wanted to know if they should bring her in but PT is Covid positive. Staff recommended that she go to the ER.    Electronically signed at 02/09/2021 9:17 AM CST    2/9 ER-> admission note: (6day admission) History The patient is a 65 y.o. female with a past medical history notable for  History of anemia, anxiety, cirrhosis, COPD, CHF, diabetes, reflux, hypertension. The patient presents for evaluation of Worsening issues of cellulitis in addition to the patient's history of recent Covid 19 infection. Patient also tested positive for influenza. Patient was started on steroids at skilled care facility. Patient was already on breathing medications. Patient has had issues with CHF and lower extremity swelling. Patient was taking a diuretic for this. Due to patient's cerebral kidney function patient is not a candidate for certain medications or either influenza, Covid 19 and we are limited on antibiotics. Patient's past medical history, past surgical history, social history, family history, medications allergies were reviewed.  3/1/21 er to admission note: currently inpatient History The patient is a 65 y.o. female presents for evaluation of altered mental status. Notable PMHx: CHF, morbid obesity, diabetes,    Patient is 3 weeks out from hospitalization for COVID-19 pneumonia.  She has been more confused over the couple of days before admission.  Because of altered mental status, patient was transferred to the emergency room.  Patient also had some shortness of breath.  In the ER, she had a chest x-ray which showed moderate interstitial infiltrate secondary to pulmonary edema or pneumonia.  Lab work did show a UTI.  BNP was normal at 45.  Creatinine was near her baseline at 1.8.  She did have elevated alkaline phosphatase at 452.  White count was elevated at 14.7.  Patient was difficult to arouse in the ER.   On my exam, patient is difficult to arouse.  After shaking her shoulder and yelling at her, she did open her eyes and say to me "I'm ok" before closing her eyes again.  She is satting well on nasal canula oxygen.