Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Fibrin D dimer increased, Haematocrit decreased
Clinical narrative: J&J Dose 9/14/21 (204B21A) COVID Positive 9/18/21  9/30/21: Patient is an 80-year-old female who presents to the ED today with complaints of shortness of breath. Patient's accompanying symptoms include generalized body aches, fatigue, fever, chills, night sweats, sore throat, dry cough, decreased appetite diarrhea, abdominal pain. Patient denies any chest pain.  Patient tested positive for COVID-19 12 days ago after being exposed to her daughter who was positive.  Patient received her Johnson & Johnson vaccination on 09/14/2021.  Patient has a past medical history significant for COPD not dependent on supplemental oxygen, and obesity.   Upon arrival to ED patient's temperature is 99.2°, heart rate 90, respirations 22, pulse ox 80% on room air, blood pressure 156/70.  Patient was placed on 4 L oxygen via nasal cannula to maintain O2 saturations greater than 90%. On 4 L patient is 90% oxygen.  Patient was given 6 mg IV Decadron, 750 mg IV Levaquin, 1 albuterol treatment in ED. Blood cultures were obtained x2.  Patient's chest x-ray reveals patchy bilateral peripheral airspace disease, concerning for viral pneumonia.  CT of chest was performed and reveals patchy bilateral ground-glass airspace disease, consistent with viral pneumonia.  Patient's laboratory values are significant for glucose 123, hemoglobin 9.3, hematocrit 32.2, MCV 73.7, MCH 21.3, MCHC 28.9, platelets 555, RDW 18.5, D-dimer 1.45, CRP 17.10.  ABGs were completed and revealed pH 7.40, pCO2 51, PO2 33, HC03 32.   Patient was seen and examined at the bedside in the ED, patient is in mild respiratory distress.  The patient remains on 3 L oxygen via nasal cannula, O2 saturation currently at 97%.  Patient continues to complain of generalized fatigue, body aches, and overall feeling ill. The patient states she tested positive for COVID-19 12 days ago after being exposed to her daughter on her birthday. The patient states she has been taking Tylenol, Aleve at home for relief of symptoms.  Patient also admits to taking hydrocodone at bedtime to help with sleep due to significant cough, body aches.  Patient denies any alcohol abuse, tobacco use, illicit drug abuse.  10/4/21: She is 80-year-old female with a history of obesity who presented to the emergency room with a complaint of worsening shortness of breath, dizziness, sore throat, nausea and anorexia for several days.  At the ER she was moderately hypoxic initially requiring 4 L of oxygen.    Further evaluation at the emergency room with chest x-ray revealed bilateral infiltrates in the lower lobes raising the possibility of a viral infection and subsequent COVID-19 screen came back negative.  Of note is that patient has been fully vaccinated against COVID-19 infection with Johnson and Johnson vaccine.  She was admitted to hospital and commenced on usual supportive treatment with supplemental oxygen, IV antibiotics levofloxacin in case there is superimposed bacterial infection, IV remdesivir and IV dexamethasone.  Patient has been gradually improving and the following day she was on room air with normal Sao2.  This morning she had O2 walk for oxygen determination and required no oxygen.  She will be discharged home and advised to follow-up with the PCP in 1-2 weeks.  She will be discharged on pre-admission medications.