Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertensive urgency, Hypervolaemia, Hypokalaemia, Hypomagnesaemia, Hypoxia
Clinical narrative: Discharge Summary     Date of Admission:  11/26/2023    Date of Discharge:  11/28/2023    Primary Care Physician:  MD   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/27/2023 12:17 AM BLOOD CULTURE 2 In process BLOOD   11/27/2023 12:15 AM BLOOD CULTURE In process BLOOD       Issues to be Addressed in Follow-up: [] increased metoprolol to 50mg daily [] continue blood pressure medications [] prescribed Doxycycline for 2 more days [] needs adjustment and titration of blood pressure medications [] complete outpatient remdesivir infusion - x 3 days   Reason for Hospital Admission (Admitting Diagnosis):  COVID    HPI on admission:  46 y/o F w/ known systolic CHF (EF of 45-50% from 2021), HTN, HL, asthma, obesity - presents to the ED for above complaints which started 2 days ago and was found to be septic and + for COVID here in the ER. Febrile and tachycardic on presentation. Hypoxic down to 88% on 1 minute march test. Was treated w/ duoneb, tylenol and decadron in the ER.   Reports that she has chronic cough d/t her asthma and CHF but has been getting worse for the past few days, also now w/ production of yellowish sputum. Reports that in the past few days, she is feeling more winded and unable to perform simple tasks w/o getting very tired and fatigued.    She also reports that her BP has been running high at home though admits that she is not always taking her BP medications.       Hospital Course: Background:   Patient Information: ? Age/Sex: 46-year-old female ? Medical History: ? Systolic Congestive Heart Failure (CHF) with an ejection fraction (EF) of 45-50% (from 2021) ? Hypertension (HTN) ? Hyperlipidemia (HL) ? Asthma ? Obesity Presentation: ? Chief Complaints: Worsening chronic cough, shortness of breath, fatigue, and uncontrolled hypertension. ? Onset: reports shortness of breath, gradually worsening for 1-2 months with increasing edema (PND and orthopnea), and fever after sick contact with daughter and recent travel (from Wed - Friday). Fever onset Sunday (day prior to presentation).  ? COVID-19 Status: Tested positive in the Emergency Department (ED). Patient's Report: ? Chronic cough attributed to asthma and CHF, recently worsened. ? Increase in fatigue and shortness of breath, impacting daily activities. ? Non-adherence to prescribed antihypertensive medications. Clinical Findings: ? Fever and tachycardia upon presentation. ? Hypoxia noted with a decrease to 88% oxygen saturation during a 1-minute march test. Treatment in ED: ? Duoneb (combination of albuterol and ipratropium) ? Tylenol (acetaminophen) ? Decadron (dexamethasone) Hospital Course: ? Diagnosis: Sepsis due to COVID 19 and acute hypoxic respiratory failure (multifactorial suspect related to COVID triggering mild asthma exacerbation and acute CHF exacerbation and volume overload.) ? Treatment: started on Remdesivir and Decadron and Oxygen supplementation. Lytes replacement and lasix. ? Complications: Asthma exacerbation due to COVID. On breathing treatment and steroids. Hypertensive urgency and home medications and IV PRN meds.  ? Suspect acute exacerbation of CHF (but had been gradually worsening edema and PND/Orthopnea for 1-2 months with medication noncompliance) and acute COVID infection which may have triggered asthma exacerbation. ? During hospitalization, increased metoprolol succinate on discharge. ? Hypoxia resolved with resolution of edema.   BP 152/85  | Pulse 106  | Temp 98.6 °F (37 °C)  | Resp 18  | Wt 96.6 kg (213 lb)  | SpO2 96%  | Breastfeeding No  | BMI 40.25 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal. No congestion.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear. No oropharyngeal exudate.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Pulses: Normal pulses.     Heart sounds: Murmur heard.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.     Comments: Mild crackles in lung bases - IMPROVED Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: no swelling present. Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity.     Right lower leg: Edema present. - resolved    Left lower leg: Edema present. - resolved Skin:    General: Skin is warm and dry.     Coloration: Skin is not jaundiced.  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.     Sensory: No sensory deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.    Hospital Course By Problem: Patient Active Hospital Problem List:   1. Sepsis due to COVID-19 (11/27/2023): ? Symptoms: Hypoxic (improving), febrile, tachycardic, fatigue, shortness of breath (SOB), cough. ? Treatments: ? Remdesivir (RDV) - 11/27 - until 11/28 - stopped due to resolution of symptoms with lasix. ? Dexamethasone (Decadron) - 11/26 - stopped on 11/28 ? Supplemental oxygen to maintain saturation ?92%. 2. Acute Hypoxemic Respiratory Failure (10/12/2021): - resolved with lasix. ? Based on symptoms and patient discussion, suspect gradual worsening of heart failure exacerbation with weight gain, volume overload for 2 months, with increasing shortness of breath and orthopnea and PND then recent travel and possible sick contact, later developed fever and found COVID infection which may have triggered asthma exacerbation. ? Hypoxia resolved. 3. Asthma, Unspecified (5/4/2016): ? Exacerbated due to current condition. Improving with breathing treatment and steroids. ? Treatments: ? Albuterol/Ipratropium (Duoneb) nebulizers every 4 hours. ? Steroids as per COVID protocol. ? Doxycycline (11/26 - active) for asthma exacerbation started on admission. X 5 days (stop limit) 4. Systolic Heart Failure, Acute (10/13/2021): ? Assessment: acute exacerbation with increasing SOB for 1-2 months, PND, Orthopnea, and elevated BNP ? Treatment: lyte replacement, resume home antihypertensives. Resume Furosemide (Lasix) 40 mg orally twice daily. Daily weight, Strict I/O ? Increased metoprolol succinate on discharge. 5. Hypertension (HTN) (5/4/2016): ? Uncontrolled blood pressure. ? Treatments: ? Resume Metoprolol and Losartan (home medications). ? Patient reports she was taken off of amlodipine over 1 year prior. (reportedly for cough) ? PRN (as needed) IV Hydralazine for systolic BP > 150. 6. Electrolyte abnormalities (hypomagnesemia / hypokalemia  ? Treatment: Electrolyte replacement as needed. Goal maintain K above 4. And Mag above 2. 7. Gastroesophageal Reflux Disease (GERD) (7/19/2021): ? Treatment: Start Famotidine (Pepcid).         Complications:  None   Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? SYSTOLIC HEART FAILURE, ACUTE   ? ACUTE HYPOXEMIC RESPIRATORY FAILURE   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)   ? HTN (HYPERTENSION)       3/30/2023: Chronic established diagnosis. Briefly reviewed plan today, cont current regimen.  strongly encouraged compliance with meds - she struggles with this    Prev note 7/20/20 - was on ccb and chlorthalidone stopped these  1/17/20 reviewed ccb and Hydrochorothiazide / HCTZ  Are great with data 9/6/19 was counseled on mi / stroke risk declined meds    She is willing to increase losartan / cozaar for blood pressure to 100 mg check labs in 2 weeks after increase    Saw cards 10/15/21 Dr 10/15/21 order nuc test - not completed / did not complete follow up echo      ? ASTHMA, UNSPECIFIED     Resolved Hospital Problems No resolved problems to display.     Primary Procedures:  none      Secondary Procedures: None   Consults:  none    Condition on Discharge:  Stable    Code Status at Time of Discharge: Full Code   Smoker: No.     Discharge Disposition:  Home   Discharge Medications: Medications, instructions, follow up information: See patient instructions (or SNF Admission orders if applicable).    Future Appointments    Appointment Date & Time Visit Type Provider Department/Facility   Feb 27, 2024  1:30 PM Mammography Screening MAMMOGRAPHY MAMMOGRAPHY         MD   11/28/2023    Note Details  Author (M.D.) File Time 11/28/2023 11:43 AM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine Admit Date 11/26/2023  ED to Hosp-Admission (Discharged) on 11/26/2023  ED to Hosp-Admission (Discharged) on 11/26/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   ASTHMA, UNSPECIFIED  HTN (HYPERTENSION)  GERD (GASTROESOPHAGEAL REFLUX DISEASE)  COVID-19 PNEUMONIA  ACUTE HYPOXEMIC RESPIRATORY FAILURE  SYSTOLIC HEART FAILURE, ACUTE Care Timeline  11/27   Admitted from ED (Observation) 1744 11/28   Discharged 1930  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/28/2023) Medication List at Discharge   atorvastatin calcium 20 mg Oral DAILY, to prevent heart attacks and strokes  clotrimazole 1 % Topical EVERY MORNING AND EVENING, for 4 weeks or as directed  doxycycline monohydrate 100 mg Oral 2 TIMES A DAY  furosemide 40 mg Oral 2 TIMES A DAY  ipratropium bromide 21 mcg (0.03 %) 2 Sprays Each nostril 2 TIMES A DAY  losartan potassium 100 mg Oral DAILY  metoprolol succinate 50 mg Oral DAILY  potassium chloride 20 mEq 20 mEq Oral DAILY  remdesivir 100 mg intraVENOUS Outpatient (Back Office), For IVPB compounded by pharmacy: After reconstitution, dilute in a 100 mL 0.9 % sodium chloride IV bag For Vial2Bag Device: Attach vial to a 100 mL 0.9 % sodium chloride IV bag using vial adapter system. Activate and dilute prior to administration. Administer immediately after activation.  Administer intravenously every 24 hours for 4 days. Following infusion, flush with 30 mL of NS Observe patient for 60 minutes after infusion is complete