Age: 49.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Asthenia
Clinical narrative: Hospitalized (12.28.21 - 12.31.21); COVID-19 positive (12.28.21); Fully vaccinated -J&J x1 D/c Summary: Discharge Summary  DO (Physician)  BRIEF OVERVIEW: Discharge Provider:  DO Primary Care Provider:  DO     Active Hospital Problems   Diagnosis Date Noted POA ? Depression 01/10/2013 Yes ? Type 2 diabetes mellitus with hyperglycemia  11/26/2012 Yes ? HTN (hypertension)   Yes ? Sleep apnea   Yes ? History of degenerative disc disease   Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute hypoxemic respiratory failure due to COVID-19 12/29/2021 12/31/2021 Yes ? Acute asthma exacerbation 12/28/2021 12/31/2021 Yes    Pre-Existing Active Problems   Diagnosis Date Noted POA ? Asthma   Unknown ? Anxiety   Unknown     Discharge Disposition:  home or self care  Discharge on home oxygen with 2L with activity and RA with rest   Active Issues Requiring Follow-up:  Acute asthma exacerbation Assessment & Plan -moderate persistent asthma:  Much improved - COVID 19 negative on 12/28 and Film array + for COVID 19 on 12/28   Plan 1.  DC home today on home nebulizers and MDI's 2.  Steroid taper over 9 days including Prednisone 40 daily for 3 days, 20 daily for 3 days, 10 daily for 3 days, then stop.   3.  Continue antibiotics including Ceftin 500 mg PO BID x 5 days for a total of 8 days of antibiotics.  Patient was on IV Rocephin the 3 days prior.  Also finish a 5 day course of Azithromycin 250 mg daily.   4.  Tobacco cessation which patient is highly motivated to quit.   5.  Follow up with PCP in a week.         * Acute hypoxemic respiratory failure due to COVID-19  Assessment & Plan - Resolved - Presented in asthma exacerbation, Covid screen negative on admission, Film array + 12/29 - 6L NC and transitioned to RA with rest and 2L with activity at discharge.  - CXR 12/31 shows no further acute pulmonary disease   Rocephin/Azithromycin, procalcitonin 0.07 (bacterial infection unlikely) -She does not wish to receive Remdesivir, so was not prescribed during this admission.  She responded well to weight based steroids. -Compliant with proning   Plan: 1.  Home O2 evaluation completed today, and patient needs no oxygen at rest and only 2L with activity.  Order written 2.  DC home today 3.  Ongoing steroid taper for asthma exacerbation.  COVID pneumonia is a lot less serious culprit.   4.  Continue home MDI regimen 5.  Complete antibiotics as above 6.  Quarantine for 10 days from start of onset of symptoms.     Type 2 diabetes mellitus with hyperglycemia  Assessment & Plan -A1c in June was 8.5, ow 10.5 - Improved, but suboptimal control -On piaglitazone, Trulicity, glipizide at home which she will resume at home. -As she remains on steroids at discharge home, will continue Lantus insulin at discharge including weight based which would put her at 45 units daily.  She can call me over the holiday weekend if she has concerns about her blood sugars for dose titration. - follow up with PCP in 1 week.       HTN (hypertension) Assessment & Plan -Well controlled on home diltiazem -DC home on Cardizem CD 120 mg PO daily.      DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute asthma exacerbation  Acute respiratory failure with hypoxia  Asthma with acute exacerbation, unspecified asthma severity, unspecified whether persistent   HOSPITAL COURSE: Very pleasant 50 y/o widowed female community dwelling patient of Dr. who was admitted on 12/28/21 for acute respiratory failure with hypoxia secondary to an acute exacerbation of her moderate persistent asthma.  In addition she had a left lower lobe atypical infiltrate.  Initial COVID PCR test was negative, but her film array was + for COVID 19, so she was placed in respiratory isolation.  The patient politely declined Remdesivir for management of her COVID 19 infection.     The patient was placed on weight based steroids for management of her COVID 19 infection and her asthma exacerbation.  She improved more quickly than expected.  She received 3 doses of IV Lasix to keep her on the dry side to avoid further edema.  Her repeat CXR on 12/31 showed resolution of this infiltrate and was a normal study.  The patient was able to transition from 6L of supplemental oxygen on admission to room air oxygen at rest with 2L required for activity.  The patient's inflammatory labs were normal.     She was medically stable for discharge home from a pulmonary standpoint with a steroid taper, ongoing antibiotics converted to PO, and home oxygen at 2L with activity.  She will resume all of her home MDI's and nebulizers.     It is likely that patient's pneumonia was not truly COVID pneumonia, because it resolved so quickly.  Perhaps she did well, because she received the COVID 19 vaccines x 2 doses.  She did however recover quickly and was able to be discharged home in 3 days from admission.     Her blood sugars were significantly elevated on admission w/ an elevated A1C indicating poor outpatient control.  She was given escalating doses of Lantus insulin with basal bolus coverage.  Her blood sugars improved.  She will continue Lantus at discharge especially as she'll be on a steroid taper for the next 9 days.  She is asked to follow up closely with her PCP regaring ongoing use of Lantus after steroids with dosing recommendations after steroids as well.  She is invited to call me with questions over the New Year's holiday weekend.     Thank you for the privilege of taking care of this very nice lady.     CONSULTS / RECOMMENDATION: None  Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES: None  Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 135/82  | Pulse 93  | Temp 36.7 °C (Temporal)  | Resp 22  | Ht 1.626 m  | Wt 94.9 kg  | SpO2 93%  | BMI 35.91 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not toxic-appearing or diaphoretic.  HENT:     Nose: Rhinorrhea present. No congestion.     Comments: Good nasal patency bilateral nares    Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No oropharyngeal exudate or posterior oropharyngeal erythema.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Comments:  Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing, rhonchi or rales.     Comments: Occasional cough Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No swelling or tenderness.     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.    H&P: CHIEF COMPLAINT: Acute asthma exacerbation     Assessment/Plan    ASSESSMENT / PLAN: * Acute asthma exacerbation Assessment & Plan -She's had a cough for a few days, minimally productive -Using her inhaler with increasingly inadequate response -She has moderate persistent asthma; has albuterol and lower dose Trelegy -Very tight in ED; given solumedrol, 3 duonebs -Will give duonebs 4x daily, PRN albuterol, high dose Symbicort, Solumedrol 40mg BID -CXR does have some left peribronchial infiltrate; treat for CAP with Rocephin/Azithromycin -Not Covid; check film array -Needs established with pulmonology; has dx of COPD too (smokes), but I see no PFT   Type 2 diabetes mellitus with hyperglycemia  Assessment & Plan -A1c in June was 8.5, repeat -On piaglitazone, Trulicity, glipizide at home -Give Lantus 10u HS with low SSI   Depression Assessment & Plan -Continue home duloxetine   History of degenerative disc disease Assessment & Plan -Continue home Norco 7.5 BID PRN   Sleep apnea Assessment & Plan -She had the admirable presence of mind to bring her CPAP--to be used here   HTN (hypertension) Assessment & Plan -Continue home diltiazem       HISTORY OF PRESENT ILLNESS: Patient  is a 50 y.o. female who presents today with asthma exacerbation. She has hx of moderate persistent asthma; smokes; also has hx of COPD and OSA. She doesn't follow with pulmonology. Also has diabetes mellitus and hypertension. She's been out of her Trelegy for a little while. She's had more frequent exacerbations since her son/daughter in law moved in with their five young children this year.    On presentation, she was tight, in distress, satting mid 80's on room air. She made improvement with steroids and duonebs. CXR with a left sided peribronchial infiltrate. She requires admission for acute asthma exacerbation.     Patient Active Problem List Diagnosis ? HTN (hypertension) ? Sleep apnea ? History of degenerative disc disease ? Asthma ? Anxiety ? Type 2 diabetes mellitus with hyperglycemia  ? Depression ? Acute asthma exacerbation Review of Systems Constitutional:  Positive for activity change and fatigue. Negative for fever.  HENT: Negative for congestion.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, wheezing, shortness of breath and chest tightness.   Cardiovascular:  Negative for chest pain, orthopnea and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Negative for joint pain, muscle pain and edema.  Neurological:  Positive for weakness. Negative for loss of consciousness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Skin:  Negative for rash and wound.          Objective    OBJECTIVE: BP 148/83  | Pulse 106  | Temp 36.9 °C (Oral)  | Resp 24  | Wt 95.3 kg  | SpO2 90%  | BMI 36.05 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed. She is ill-appearing.     Comments: Talking in full sentences, laughing, on duoneb via Venturi.   HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Comments: Mild increased work of breathing. Lungs sound somewhat tight with wheezing, but I do hear air movement throughout. Good inspiratory effort.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.