Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Essential hypertension, Full blood count, General physical condition abnormal, Glomerular filtration rate normal, Haematocrit decreased
Clinical narrative: Chief Complaint:  SOB   History Of Present Illness: Patient is a 76 y.o. male with pulmonary fibrosis and h/o right upper lobectomy who came to the ER with SOB, cough and fever which started yesterday. He had 100.1 degree fever on arrival here. He tested (+) for Covid-19. He only had single dose of J&J vaccine. He is being admitted.     Past Medical History:  Patient  has a past medical history of Bladder cancer, Bladder tumor, CAD (coronary artery disease), Chronic kidney disease, stage 3, COPD (chronic obstructive pulmonary disease), Diabetes, DOE (dyspnea on exertion), Former cigarette smoker, Hypertension, Lung nodule, Malignant neoplasm of upper lobe of right lung, Mediastinal lymphadenopathy, Obesity (BMI 30-39.9), Phimosis, Prostate cancer, Pulmonary nodules (10/2021), S/P angioplasty with stent (12/11/2020), and Sleep apnea.   Past Surgical History:  Patient's  has a past surgical history that includes Hx Cardiac Catheterization; Hx Broken/Fx Bones; Hx Prostate Biopsy; Hx Knee Arthroscopy (Right); Hx Cystoscopy (Bilateral, 5/9/2019); Hx Cystoscopy (N/A, 5/9/2019); Hx Cystoscopy (Bilateral, 4/19/2018); Hx Cystoscopy (4/19/2018); Hx Cystoscopy (N/A, 8/10/2017); Left heart cath (N/A, 8/15/2012); IVUS (N/A, 8/15/2012); Drug-eluting stent placement (N/A, 8/15/2012); Left heart cath (N/A, 10/8/2011); Drug-eluting stent placement (N/A, 10/8/2011); Left heart cath (N/A, 12/17/2020); Drug-eluting stent placement (N/A, 12/17/2020); CT Guided Lung Biopsy (Right, 10/27/2021); Hx Thoracoscopy (Right, 12/9/2021); Hx Bronchoscopy (N/A, 12/9/2021); Hx Arterial Line Insertion (12/9/2021); Hx Intercostal Nerve Block (Right, 12/9/2021); Hx Thoracotomy (Right, 12/9/2021); and Hx Biopsy (Right, 12/9/2021).   Family History:   Patient's family history includes Alzheimer's Disease in his father; Cancer in his sister; Diabetes in his brother and mother; Heart Disease in his brother; Renal Disease in his mother.      Social History:  He  reports no history of alcohol use.  He  reports no history of drug use.  He  reports that he quit smoking about 17 years ago. His smoking use included cigarettes. He has a 17.50 pack-year smoking history. He has never used smokeless tobacco.    Allergies:  Lisinopril, Sulfa (sulfonamide antibiotics), and Tuberculin ppd   PTA Medications:  Prior to Admission Medications Prescriptions Last Dose Informant Patient Reported? Taking? Budesonide-Formoterol (SYMBICORT) 160-4.5 mcg/Actuation inhaler     No No Sig: Take 1 Puff by inhalation Twice a day. Insulin Syringe-Needle U-100 (BD INSULIN SYRINGE ULTRA-FINE) 1 mL 31 gauge x 5/16 Syrg     No No Sig: 1 Syringe As directed. albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler     No No Sig: Take 1 Puff by inhalation Every 4 hours as needed (WHEEZING). amLODIPine (NORVASC) 10 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. ascorbic acid, vitamin C, 500 mg tablet     Yes No Sig: Take 500 mg by mouth Daily. aspirin (ASPIRIN) 81 mg DR tablet     Yes No Sig: Take 325 mg by mouth Once Daily. atorvastatin (LIPITOR) 20 mg tablet     No No Sig: Take 1 Tablet by mouth At bedtime. blood sugar diagnostic test strips     No No Sig: by Other route Three times a day. One Touch Ultra.  Diagnosis E11.65 carvediloL (COREG) 25 mg     No No Sig: Take 1 Tablet by mouth Twice a day. cloNIDine (CATAPRES) 0.1 mg/24 hr patch     No No Sig: 1 Patch by Transdermal route Every 7 days. clopidogreL (PLAVIX) 75 mg tablet     No No Sig: Take 1 Tab by mouth Daily. docusate sodium (COLACE) 100 mg capsule     No No Sig: Take 1 Capsule by mouth Twice a day as needed for Constipation. losartan (COZAAR) 50 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. metFORMIN (GLUCOPHAGE) 1,000 mg tablet     No No Sig: Take 1 Tablet by mouth Twice a day.  Facility-Administered Medications: None       Review of Systems:  Review of Systems  Unable to perform ROS: Acuity of condition        Physical Exam: Blood pressure 132/75, pulse 88, temperature 100.1 °F (37.8 °C), temperature source Oral, resp. rate (!) 29, SpO2 96 %. Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is ill-appearing.  HENT:     Head: Normocephalic.  Eyes:     General: No scleral icterus.    Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm.     Heart sounds: No murmur heard. Pulmonary:     Effort: No respiratory distress.     Breath sounds: Rhonchi present.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: No tenderness.     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.         Labs:   CBC:  Lab Results Component Value Date/Time   WBC 8.6 06/25/2022 2125   RBC 4.16 06/25/2022 2125   HGB 11.6 06/25/2022 2125   HCT 34.1 06/25/2022 2125   MCV 81.9 06/25/2022 2125   MCH 27.9 06/25/2022 2125   MCHC 34.0 06/25/2022 2125   RDW 14.8 06/25/2022 2125   MPV 8.3 06/25/2022 2125   PLATELETCNT 307 06/25/2022 2125   Cardiac Enzymes:  Lab Results Component Value Date/Time   CK 98 10/08/2011 1630   CKMB 1.8 10/08/2011 1630   TROPONINI <0.03 06/25/2022 2126   CMP:  Results for orders placed or performed during the hospital encounter of 06/25/22 (from the past 72 hour(s)) Comprehensive Metabolic Panel   Collection Time: 06/25/22  9:26 PM Result Value Ref Range   SODIUM 135 135 - 145 mmol/L   POTASSIUM 3.7 3.6 - 5.0 mmol/L   CHLORIDE 99 (L) 101 - 111 mmol/L   CO2 21 21 - 31 mmol/L   ANION GAP 15     GLUCOSE 125 (H) 70 - 110 mg/dL   CREATININE 1.0 0.6 - 1.2 mg/dL   BUN 15 2 - 32 mg/dL   CALCIUM 8.5 8.5 - 10.5 mg/dL   PROTEIN TOTAL 6.7 6.1 - 7.8 g/dL   Albumin 3.7 3.2 - 5.0 g/dL   T BILIRUBIN 0.4 0.2 - 1.0 mg/dL   ALP 66 42 - 121 [iU]/L   AST 65 (H) 10 - 42 [iU]/L   ALT (SGPT) 38 10 - 60 [iU]/L   OSMOLALITY 272 266 - 309   A/G Ratio 1.2     B/C 15 10 - 20   ESTIMATED GFR 73 mL/min   Magnesium  Lab Results Component Value Date/Time   MAGNESIUM 1.2 06/25/2022 2126   SARS-CoV-2 RNA Detected        Imaging:  Reviewed     ASSESSMENT/PLAN:   Problems and Relevant Co-morbid conditions:: Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Type 2 diabetes mellitus with diabetic nephropathy, without long-term current use of insulin   Essential hypertension       * Pneumonia due to COVID-19 virus Remdesivir, steroid, and ancillary medications started. Self proning encouraged. Incentive spirometer ordered. CHO diet. SS. Will continue appropriate regular medications.