Age: 76.0
Sex: F
Vaccine: COVID19
Symptoms: Bilevel positive airway pressure, Blood glucose increased, Blood magnesium increased, Bordetella test negative, COVID-19
Clinical narrative: Hypoxia & Shortness of breath Chief Complaint Patient presents with ? Shortness of Breath     x 3 days, denies any cough, congestion, or fever. daughter is with her. Oxygen very low 74, provider notified right away and he came into room.   ED to Hosp-Admission Discharged  4/15/2021 - 4/17/2021 (2 days)   Last attending ? Treatment team Aspiration pneumonia of left lower lobe, unspecified aspiration pneumonia type (HCC) Principal problem Hospital Course      HPI: a 76 y.o. female presenting to the ED with chief complaint of chest pain and shortness of breath.  Patient is being seen in the emergency department for evaluation of the above, here with her daughter.  Patient was seen and evaluated by local urgent care and referred here for evaluation.  Is reported that patient was hypoxic.  Patient's daughter also states that they have been monitoring her oxygen saturation at home and it has been in the 60s and 80%.  Patient does report a cough.  She has been using her inhaler more frequently.  Received her Covid vaccination 2 days ago.   Hospital Course:  Patient was admitted and placed on supplemental O2.  Chest x-ray 4/15/2021 showed some opacity at the left costophrenic angle effusion with some areas of atelectasis possible.  Chest CT performed on 4/16/2021 revealed small areas of consolidation/infiltrate in the right upper and left lower lobes of the lungs, emphysema, and a 3 mm pulmonary nodule in the left upper lobe.  Small bilateral pleural effusions have decreased since CT of12/11/2020.  Initial CBC revealed white blood cell count of 9.3.  Hemoglobin and hematocrit were stable at 8.8 and 29.4.  Renal function was stable as well.  Glucose on 4/16/2021 fasting was 222.  Magnesium was at goal at 2.5.  Procalcitonin levels were performed and were 0.19.  She was initially started on IV vancomycin and cefepime as well as Flagyl due to possible aspiration pneumonia.   On 4/17/2021, patient was adamant on being discharged.  She did discuss possibly signing out AMA.  I did explain to her the ramifications of that.  She voiced understanding.  I also discussed this with her daughter, as well.  She required 4 L of supplemental O2 and achieved an O2 sat of 93%.  On room air patient was 78%.  Therefore, home O2 was ordered.  IV antibiotics were changed to oral Levaquin 250 mg to take 1 by mouth daily (based on renal function) for 7 days and generic Flagyl 500 mg to take 1 3 times a day for 7 days.  She was instructed to take antibiotics as prescribed as well as use supplemental O2.  She was also advised that if symptoms worsened she was to return to the emergency room.   At time of discharge she was stable with supplemental O2 in place.  ED to Hosp-Admission Discharged  4/28/2021 - 5/4/2021 (6 days)    Last attending ? Treatment team    Hospital Course     HPI:  a 76 y.o. female with a past medical history of systolic and diastolic heart failure, diabetes mellitus type 2, above-the-knee amputation of left lower extremity, who comes from home where her oxygen saturation as per the daughter was 25%.  She was recently discharged from here on 4/17/2021 for left lower lobe pneumonia.  She does not want to be in the hospital.  She states that she felt fine when she came in this time.  She was evaluated by the ICU who stated she is a DNR/DNI and felt that with BiPAP modification she was satting better.  She was adamant that she wanted to leave the last time she was here and went home with oral Levaquin and Flagyl.  When she arrived, nursing states that there was dried stool on her bottom.  The patient denies any current shortness of breath.  She wants her BiPAP mask removed as it is uncomfortable to her.  After explaining it as needed she agreed to have it on.  She denies any abdominal pain, she denies any chest pain.  She denies any fevers or chills.   Hospital Course:   Patient was admitted for acute on chronic diastolic CHF, acute on chronic hypoxic respiratory failure secondary to CHF and COVID-19.  Patient was also treated for elevated blood pressures.  Cardiology was consulted, patient was placed on Lasix twice daily and was started on hydralazine for blood pressure.  From pneumonia standpoint, patient started on Zosyn, for COVID-19 patient was started on Decadron and remdesivir.  Patient finished a course of remdesivir in the hospital.  Patient went from using 5 L oxygen to only 1 L, meanwhile chronically she has been using 3 L at home prior to coming into the hospital.  Patient has not been requiring any further BiPAP.  She has been afebrile for more than 48 hours.  Today nephrology recommended to lower Lasix down to once daily instead of twice daily to avoid kidney injury.  Patient is medically stable for discharging home today to finish her course of Augmentin and Decadron.  Patient appears to be very hesitant about having to continue self isolating.  Family understands the need for further isolation.  Patient will receive a remote monitoring kit upon discharge. ED to Hosp-Admission Discharged  5/10/2021 - 5/17/2021 (7 days)    Last attending ? Treatment team Pneumonia due to COVID-19 virus Principal problem   Hospital Course     HPI: Patient was admitted with hypoxia and pneumonia due to COVID-19 virus.  For details please see the history and physical.   Hospital Course:   Patient had previously been diagnosed with COVID-19 pneumonia about 3 weeks ago and had been treated with remdesivir Decadron and antibiotics.  She was now admitted with pneumonia and hypoxemia.  Her oxygen requirement went up and she was at 1 point requiring high flow oxygen up to 15 L/min.  Subsequently her oxygen requirement was able to be tapered.  She was treated with steroids during this hospitalization.  Her oxygen requirement is now down to 4 L/min.  She is feeling better.  She is now felt stable for discharge with outpatient follow-up with her PCP.  Steroids have been stopped on discharge.  Her daughter was regularly updated during this hospitalization.  I called and left a message at the time of discharge today.