Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Alanine aminotransferase increased, Anion gap, Aspartate aminotransferase normal, Atelectasis, Basophil count decreased
Clinical narrative: Hospitalized (1.4.22 - 1.8.22); COVID-19 positive (1.5.22); Fully vaccinated -J&J x1 d/c summary: Discharge Summary FNP (Nurse Practitioner) ? ? Hospitalist Cosigned by: MD at 1/8/2022  2:45 PM Attestation signed by, MD at 1/8/2022  2:45 PM I have personally interviewed and examined the patient on 1/8/2022. Management was discussed with NP. I agree with the documented findings and plan of care in his/her note.   Brief exam:  Cardiac-regular rate and rhythm without murmur, no edema and no jugular venous distention Lungs-soft wheezes Abdomen-soft nontender nondistended with normal bowel sounds Neuro-alert oriented, no focal deficits     Brief history and medical decision making:  Active Problems:   Coronary artery disease      Essential hypertension   Tobacco dependence   COVID-19 71 year old female admitted with COVID and COPD exacerbation.  She was treated with steroids, bronchodilators and remedesivir.  Her condition improved rapidly and she was discharged home in stable condition to complete a course of steroids.  She will follow up with her PCP as an outpatient.      Expand All Collapse All Discharge Summary    BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider at Discharge: PA-C   Admission Date: 1/4/2022 Discharge Date: 1/8/2022    Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 01/05/2022 Unknown ? Tobacco dependence 04/20/2017 Yes ? Essential hypertension 01/05/2016 Yes ? Coronary artery disease    01/05/2016 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? COPD with acute exacerbation   01/05/2022 01/08/2022 Unknown ? Hypoxia 01/06/2022 01/08/2022 Unknown DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia [R09.02] COPD with acute exacerbation (HCC) [J44.1] Dyspnea, unspecified type [R06.00] COVID-19 [U07.1]   HOSPITAL COURSE: Patient is a 71 year old female patient with a history of tobacco use, COPD, chronic back pain, CAD, and HTN who presented to ER with worsening shortness of breath that started on 1/1/22. The patient reports increasing shortness of breath for 6 months, but the recent shortness of breath was intolerable and she called EMS. She has been working on tobacco cessation and was started on Wellbutrin in the last week.  She denied fever, chills,headache, body aches, loss of sense of taste or smell, nausea, vomiting, and diarrhea. The patient had noted hypoxia in ER with ambulation requiring 2 liters to maintain saturations above 90%. Her BNP was elevated to 2,749, troponins were indeterminate at 23 and 26, EKG did not show ischemic changes.  The patient tested negative on the rapid covid test and then returned positive on film array. Chest x ray showed COPD and chronic bibasilar atelectasis/scarring without acute cardiopulmonary process.  The patient is being admitted with COPD exacerbation related to Covid infection for further treatment and monitoring.   Patient was treated with Remdesivir, steroids, Azithromycin and aggressive pulmonary hygiene. She improved and was able to be weaned off oxygen and remained stable on room air. She had heartburn that improved with addition of Pepcid which was prescribed at time of discharge. She was discharged home with husband in stable condition with a prescription for tapered dose prednisone, 2 days of Azithromycin and Nicotine patch to assist with smoking cessation. She was instructed to follow up with her PCP in 5-7 days. All questions and concerns addressed prior to discharge.     CONSULTS / RECOMMENDATION: none   INPATIENT PROCEDURES: none   BP 123/54  | Pulse 70  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.74 m  | Wt 93.3 kg  | SpO2 95%  | BMI 30.82 kg/m²  FIO2 (%): 2 % Physical Exam Vitals reviewed.  Constitutional:      General: She is awake. She is not in acute distress. HENT:     Head: Normocephalic and atraumatic.  Neck:     Comments: No JVD Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No swelling. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal. Behavior is cooperative.    H&P: CHIEF COMPLAINT: COPD with acute exacerbation       Assessment/Plan    ASSESSMENT/PLAN:   Principal Problem:   COPD with acute exacerbation   Active Problems:   Hypoxia   COVID-19   Coronary artery disease      Essential hypertension   Tobacco dependence         * COPD with acute exacerbation   Assessment & Plan Patient with worsening shortness of breath for 6 month, but acutely worse in last 4 days prompting a call to EMS on 1/4/22. Patient requiring 1-2 liters to maintain sats greater than 90%. Exacerbation likely related to Covid infection. BNP elevated though patient does not have edema and CXR does not show pulmonary congestion.   -Solumedrol 40 mg TID -sub Spiriva and Symbicort in place of Trelegy -albuterol prn -Azithromycin for inflammation -IS and flutter -guaifenesin -Continuous pulse ox   Hypoxia Assessment & Plan Patient with work of breathing and hypoxia with activity requiring 2 liters.  Oxygen decreased to 1 liter at rest.   -Oxygen per protocol -continuous pulse ox   COVID-19 Assessment & Plan Symptoms started 1/1/22. Covid positive 1/5/21. Fully vaccinated, overdue for booster   -continue Remdesivir -see plan for COPD exacerbation -daily CMP, CBC, Ddimer, CRP -lovenox for DVT prophylaxis   Tobacco dependence Assessment & Plan Patient has been trying to quit tobacco cigarettes and has weaned from 2 ppd to half a pack per day. She was started on wellbutrin 4-5 days ago, and was stopped in ER in the case it was contributing to her symptoms, this was done prior to learning patient was covid positive.   -Restart wellbutrin and monitor for signs of intolerance. -nicotine 14 mcg daily   Essential hypertension Assessment & Plan Continue PTA medications   Coronary artery disease    Assessment & Plan Continue atorvastatin and blood pressure control medications       This documentation done via software. It should also  be noted that  typing  using the software skips and jumps  transposing one phrase to the next . Although the note has been reviewed, it may contain  grammatical and typographic inaccuracy.   HISTORY OF PRESENT ILLNESS: Patient is a 71 y.o. female with a history of tobacco use, COPD, chronic back pain, CAD, and HTN who presented to ER with worsening shortness of breath that started on 1/1/22. The patient reports increasing shortness of breath for 6 months, but the recent shortness of breath was intolerable and she called EMS. She has been working on tobacco cessation and was started on Wellbutrin in the last week.  She denied fever, chills,headache, body aches, loss of sense of taste or smell, nausea, vomiting, and diarrhea. The patient had noted hypoxia in ER with ambulation requiring 2 liters to maintain saturations above 90%. Her BNP was elevated to 2,749, troponins were indeterminate at 23 and 26, EKG did not show ischemic changes. The patient tested negative on the rapid covid test and then returned positive on film array. Chest x ray showed COPD and chronic bibasilar atelectasis/scarring without acute cardiopulmonary process.  The patient is being admitted with COPD exacerbation related to Covid infection for further treatment and monitoring.. OBJECTIVE: Review of Systems Constitutional:  Positive for appetite change and chills. Negative for activity change, diaphoresis, fatigue and fever.  HENT: Negative for congestion, rhinorrhea, sneezing and sore throat.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing, chest tightness and sputum production.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Neurological:  Negative for headaches, dizziness and weakness.    BP 116/52  | Pulse 88  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.74 m  | Wt 93.3 kg  | SpO2 99%  | BMI 30.82 kg/m²  FIO2 (%): 2 % Physical Exam Constitutional:      General: She is awake. She is not in acute distress.    Appearance: She is overweight. She is not ill-appearing or toxic-appearing.  HENT:     Nose: Nose normal. No congestion or rhinorrhea.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No tachypnea or accessory muscle usage.     Breath sounds: Examination of the right-lower field reveals decreased breath sounds. Examination of the left-lower field reveals decreased breath sounds. Decreased breath sounds present. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not pale.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal. Behavior is cooperative.        Thought Content: Thought content normal.        Judgment: Judgment normal.