Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Mean platelet volume normal, Metabolic function test, Neck pain, Oropharyngeal pain, Pain in extremity
Clinical narrative: Hospitalized (12.24.21 - 12.25.2021); COVID-19 positive (12.22.21); Fully vaccinated -pfizer x2 Pt reports positive COVID home test to PCP on 12/17/21.   Noted to have received Monoclonal antibody infusion on 12/22/21  hospital d/c summary: Discharge Summary  I have seen and examined patient independently. Discussed with Dr. I agree with the subjective and physical exam findings and assessment and plan.    Expand All Collapse All  BRIEF OVERVIEW: Admission Date: 12/24/2021 Discharge Date: Dec 25, 2021    Active Hospital Problems No active problems to display.   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Chest pain 12/24/2021 12/25/2021 Unknown    Pre-Existing Active Problems   Diagnosis Date Noted POA ? COVID 12/21/2021 Unknown ? Osteomyelitis of vertebra, lumbar region  03/10/2021 Unknown ? Sacroiliitis, not elsewhere classified  01/01/2021 Unknown ? Bunion of right foot 12/17/2020 Unknown ? Lumbar spine pain 05/30/2019 Unknown ? Gastroesophageal reflux disease without esophagitis   Unknown ? Benign positional vertigo, unspecified laterality 01/11/2017 Unknown ? Benign essential hypertension 10/31/2016 Unknown ? Hyperlipidemia, unspecified hyperlipidemia type 04/26/2016 Unknown ? Osteopenia of spine 10/20/2014 Unknown ? Heart murmur 10/20/2014 Unknown ? Aortic valve sclerosis 10/20/2014 Unknown ? Personal history of colonic polyps   Unknown ? Cervical spine arthritis 10/11/2011 Unknown ? Hx of colonic polyp 10/11/2011 Unknown ? Bilateral low back pain with sciatica, sciatica laterality unspecified, unspecified chronicity 10/11/2011 Unknown     Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:    Covid-19 infection - Recommend close monitoring of symptoms and seeking further medical care if worsening from an infectious standpoint    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Chest pain  Chest pain, unspecified type  COVID    HOSPITAL COURSE: Patient is an 87yo female w/ hx of aortic sclerosis and hypertension who presents in COVID+ status w/ new onset chest discomfort. She was admitted to observation while awaiting stress testing via lexiscan due to inability to maintain adequate exercise on treadmill.    Her cardiac workup was largely unremarkable, due to concern for inability to rule out pulmonary embolism, d-dimer was obtained which was normal, so CT angio was not done.    Patient tolerated Lexiscan without complication and was discharged home without further exacerbation of her chest discomfort or covid related symptoms.        CONSULTS / RECOMMENDATION:    Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:    Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 130/74  | Pulse 79  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.499 m  | Wt 56.4 kg  | SpO2 98%  | BMI 25.11 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed.  Eyes:     General: No scleral icterus. Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.    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. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced or pale.     Findings: No bruising, erythema, lesion or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Motor: No abnormal muscle tone.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.   H&P: I have seen and examined patient independently. Discussed with Dr. I agree with the subjective and physical exam findings and assessment and plan.    Expand All Collapse All     Hide copied text  Hover for details   CHIEF COMPLAINT: Chest pain     Assessment/Plan     ASSESSMENT / PLAN: Patient is a previously healthy 87yo female with hx of aortic sclerosis COVID 19 infection with first symptoms on 12/14 who presents with new onset neck, back, and arm pain as well as reflux symptoms that were concerning for new chest pain. Normal troponins, ekg w/ LBBB without significant change from previous ekg. Echo 6/2021 reveals dyssynchronous septal motion consistent w/ conduction abnormality as well as aortic sclerosis w/out stenosis. Patient admitted to obs for monitoring and further stress testing.   Chest pain Aortic sclerosis Troponins unremarkable, EKG unchanged from previous with known left bundle branch block.  No ongoing shortness of breath, however patient did feel lightheaded with chest heaviness prior to admission. - will obtain Lexiscan, patient unable to walk on treadmill - tele - will obtain D-dimer, will undergo CT angiogram if elevated   HTN History of hypertension well controlled with low-dose Norvasc 2.5 mg.  Will continue.   Code status: full DVT prophylaxis:  Lovenox Diet:  General Lines:  Peripheral IV Dispo:  Observation following stress testing   Please refer to attending attestation for further details.             Subjective     HISTORY OF PRESENT ILLNESS: Patient is a 87 y.o. female who presents today with recent COVID-19 infection symptoms beginning on 12/14 who presents with new onset chest, neck, back, and arm pain since this morning.  She states that she awoke from sleep at approximately 4:00 a.m. felt dizzy and lightheaded and was having aches in her chest that she associated with reflux as well as pain in her neck back and arms.  She got up from bed and took aspirin which provided some relief, however given her ongoing discomfort she called EMS.   In the emergency department her symptoms were relieved after receiving nitroglycerin in route to the emergency department.  Her workup was largely unremarkable however given her chest discomfort in the setting of recent COVID infection, decision was made to admit for observation while awaiting stress testing.    Patient Active Problem List Diagnosis ? Cervical spine arthritis ? Hx of colonic polyp ? Bilateral low back pain with sciatica, sciatica laterality unspecified, unspecified chronicity ? Personal history of colonic polyps ? Osteopenia of spine ? Heart murmur ? Aortic valve sclerosis ? Hyperlipidemia, unspecified hyperlipidemia type ? Benign essential hypertension ? Benign positional vertigo, unspecified laterality ? Gastroesophageal reflux disease without esophagitis ? Lumbar spine pain ? Bunion of right foot ? Osteomyelitis of vertebra, lumbar region ? Sacroiliitis, not elsewhere classified  ? COVID ? Chest pain  Review of Systems Constitutional:  Negative for fever.  HENT: Positive for sore throat. Negative for congestion.  Eyes: Negative for eye discharge and visual disturbance.  Respiratory:  Positive for shortness of breath and chest tightness. Negative for cough and wheezing.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Negative for vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Negative for joint pain and muscle pain.  Neurological:  Positive for dizziness and light-headedness. Negative for loss of consciousness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Skin:  Negative for rash.          Objective    OBJECTIVE: BP 169/74  | Pulse 80  | Temp 97.7 °F (36.5 °C) (Oral)  | Resp 16  | Wt 56.9 kg (125 lb 7.1 oz)  | SpO2 95%  | BMI 25.34 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed.  HENT:     Head: Normocephalic.     Nose: No congestion or rhinorrhea.  Eyes:     General: No scleral icterus. Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.     Comments: Bibasilar crackles 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. Normal range of motion.     Cervical back: Normal range of motion.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced or pale.     Findings: No bruising, erythema, lesion or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Motor: No abnormal muscle tone.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal