Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19 pneumonia, Central venous catheterisation, Chest X-ray abnormal, Chronic kidney disease, Cough
Clinical narrative: Hospitalized (5.11.22 - 5.14.22); COVID-19 positive (5.11.22); fully vaccinated PLUS Booster - moderna x4 Discharge Summary MD (Physician) ? ? Hospitalist  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: DO Admission Date: 5/11/2022 Discharge Date: May 14, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia 05/12/2022 Unknown ? COVID-19 05/11/2022 Unknown ? Thrombocytopenia (HCC) 03/03/2022 Yes ? MDS (myelodysplastic syndrome)   10/24/2021 Yes ? Chronic kidney disease, stage 4 (severe)     DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 [U07.1]   HOSPITAL COURSE: Patient was admitted for COVID-19 pneumonia, however she was not hypoxic and  steroids/remdesivir where not started.  Procalcitonin was elevated has transferred the know of is superimposed bacterial pneumonia on IV cefepime and doxycycline was started on admission.  Patient has remained afebrile no leukocytosis cultures have remained negative to date.  Further workup had shown the patient was positive for mycoplasma, she has been on doxycycline on on discharge today she will be discharged with oral azithromycin Patient is said to be able to move around independently as per his nurse He is advised to follow with his family physician Consult Orders (From admission, onward)   None  INPATIENT PROCEDURES: BP 167/88  | Pulse 79  | Temp 36.6 °C (Temporal)  | Resp 18  | Ht 1.651 m  | Wt 57.6 kg  | SpO2 96%  | BMI 21.13 kg/m²  FIO2 (%): 21 % Physical Exam HEENT normocephalic atraumatic Neck supple Lungs good entry bilaterally no wheeze or crackle Cardiovascular S1-S2 present no murmur Abdomen soft nontender nondistended no guarding no rigidity Extremities  chronic venous stasis changes Neurology  examination nonfocal   H&P:  CHIEF COMPLAINT:          COVID-19 ASSESSMENT / PLAN: 1. COVID-19 pneumonia, patient is not hypoxic, she is on room air saturating 93%, I would not start steroids or remdesivir.  Without breathing treatments p.r.n., zinc, ascorbic acid and thiamine.  Will monitor closely 2. Possible superimposed bacterial pneumonia, lactic acid is normal but procalcitonin is elevated, would continue IV cefepime and doxycycline, with other urine antigen for Legionella, strep and also mycoplasma.  3. GERD on PPI  4. Continue home eyedrops for history of glaucoma  5. DVT prophylaxis SCD, no heparin because of thrombocytopenia  6. History of myelodysplastic syndrome, would continue outpatient follow-up  7. Chronic kidney disease stage 4 said to be around baseline, will avoid nephrotoxic medications HISTORY OF PRESENT ILLNESS: Patient is a 76 y.o. female who presents today with complaint of shortness of breath and cough.  Blood patient has a history of myelodysplastic syndrome, gets blood transfusions certainly, also history of Crohn's disease with colostomy.  She claims she went to her oncologist office today for a visit with, during the visit she was having shortness of breath was directed to come to the ER for evaluation.  She however claims no shortness of breaths systems all resolved.  However she is presently on room air saturating above 90%, she reports on productive cough, no low-grade fever, no chest pain no diaphoresis.  She claims she was expose the COVID-19, has son is said to have COVID-19 and she was in contact with him last week .  She however is fully vaccinated with COVID vaccine.  She denies nausea vomiting no abdominal pain no diarrhea.  Denies urinary symptoms no leg pains no leg swelling  COVID-19 was positive OBJECTIVE: BP 107/83  | Pulse 91  | Temp 36.8 °C (Oral)  | Resp 26  | Wt 52.6 kg  | SpO2 93%  | BMI 19.30 kg/m²    Physical Exam HEENT normocephalic atraumatic Neck supple Lungs good entry bilaterally I do not appreciate any wheeze or crackle Cardiovascular S1-S2 present no murmur Abdomen soft nontender nondistended no guarding no rigidity Extremities no calf tenderness no cyanosis no edema, but has chronic venous stasis changes Neurology cranial nerves grossly intact examination nonfocal