Age: 27.0
Sex: F
Vaccine: COVID19
Symptoms: Computerised tomogram abdomen abnormal, Computerised tomogram abnormal, Condition aggravated, Cough, Crying
Clinical narrative: Discharge Physician: MD, MPH Primary Care Physician: DO  Date of Admission: 11/13/2022 Discharge Date: 11/18/2022  PRESENTING PROBLEM: Shortness of breath [R06.02] Sepsis [A41.9] Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present [A41.9] COVID-19 [U07.1] COVID positive date: 11/10/2022   HOSPITAL COURSE: 28 y.o. female who presented today to the ER secondary to fever, cough and congestion.  During her 3rd trimester, she test positive for COVID with a home test 09/2021.    Upon arrival to the ER, the patient had temperature of 38° and she was tachycardic. Lab workup showed hypokalemia, leukocytosis, elevated BNP and a procalcitonin.  Lactic acid was normal.  UA was negative.  CT angiography of the chest showed no evidence of pulmonary embolism but showed bibasilar atelectasis with atelectasis in the left upper lobe and small bilateral effusion.  CT abdomen pelvis showed small amount of free intraperitoneal air in the abdomen the pelvis, postcholecystectomy changes together with hepatosplenomegaly, extensive body wall edema and small bilateral pleural effusion.  There was noted colonic wall thickening at the hepatic flexure on a CT that was done 11/10/2022 which seem to have resolved with the current CT.  Doppler ultrasound of the left upper extremity showed acute occlusive superficial venous thrombosis in the branch of the basilic vein with no evidence of DVT.  In the ER, blood cultures were obtained she was started on Zosyn.  During my evaluation, she was emotional, crying for not being able to stay at home with her newborn since delivery.  The patient will be admitted to the hospital with sepsis possibly secondary to pneumonia with positive COVID-19 infection. She was noted to be iron deficiency and started on IV iron replacement. Patient's IV infiltrated and did not wish for additional IV placed given all other oral medications. IV iron discontinued after x1 dose and transitioned to PO iron supplementation. Electrolytes were monitored and repleted PRN throughout the admission. Patient clinically improved and hemodynamically stable for discharge.  Discussed plan of care discharge with patient including outpatient follow-up PCP within 7 days. Patient voiced understanding was agreeable with plan of care discharge.  Vaginal delivery at Hospital  Admission Date: 11/4/2022 Discharge Date: 11/7/2022  PROCEDURES PERFORMED:   HOSPITAL COURSE: Patient is a 28 y.o. female G1P1001 underwent an uncomplicated vaginal delivery and was discharged home in stable condition. Delivered a live male infant Edinburgh Edinburgh Postnatal Depression Scale Total: 9  DELIVERY TYPE: Vaginal, Vacuum (Extractor)    ESTIMATED DUE DATE: Estimated Date of Delivery: 11/4/22 GESTATIONAL AGE AT DELIVERY: 40w1d  G1P1001 DELIVERY PROVIDER:  ASSISTING PROVIDER(S):  FINDINGS: NEWBORN STATUS: Living  NEWBORN SEX:  boy  Delivery Date/Time:  2:21 PM  2. Fetal well being: - cat I - baseline 145, moderate variability, + accels, - decels - Cephalic by bedside ultrasound - EFW 8.5lbs by Leopold's - Pelvis appears adequate and unproven - anterior placenta - US 7/18: EFW 755g, 66%ile, AC 42%ile, AFI nml    3. Maternal well being:  - Stable condition  - COVID in pregnancy MD Resident Obstetrics Cosigned by: MD