Age: 33.0
Sex: F
Vaccine: COVID19
Symptoms: Peripheral swelling, Platelet count normal, Pleural effusion, Pleuritic pain, Pneumonia
Clinical narrative: Hospitalized (12.11.21 - 12/13/21); COVID-19 positive (12.11.21); Fully vaccinated - pfizer x2   H&P: Attestation signed by DO at 12/12/2021  5:14 PM I have personally interviewed and examined the patient on 12/12/2021. Management was discussed with PA-C. I agree with the documented findings and plan of care in his/her note.   Brief exam, history and medical decision making: Patient seen and examined in ED room 07-1.  Sitting up in bed, in no apparent distress.  States her cough "isn't too bad."  Still feels short of breath, and is currently on 2 L oxygen.  She has been ill since 12/09, marked by fever/chills, cough, shortness of breath and pleuritic chest pain.  She was hypoxemic, and was placed on 2 L oxygen.  Covid test positive.  She is vaccinated (6/18, 7/10).  On exam, she has diminished breath sounds bilaterally.  Heart is regular rate and rhythm.  She is obese with nontender/nondistended abdomen.  1+ edema in bilateral lower extremities.  Continue treatment with remdesivir and Decadron.  Otherwise symptomatic care.  Wean oxygen as able.     Expand All Collapse All     Hide copied text  Hover for details   CHIEF COMPLAINT: Acute hypoxemic respiratory failure due to COVID-19 (HCC)     Assessment/Plan     ASSESSMENT / PLAN: * Acute hypoxemic respiratory failure due to COVID-19 (HCC) Assessment & Plan ..Vaccination status: 2 doses of pfizer, no booster Symptom onset: 12/9/21 Current oxygen requirement: 2 L NC Qualifies for treatment with: Remdesivir, decadron VTE prophylaxis: Lovenox subQ Symptom management with: tylenol, mucinex, tessalon, cepacol, albuterol inhaler Discussed benefit of proning as tolerated Telemetry and continuous pulse oximetry monitoring Trend labs including CMP, CBC, ddimer, CRP Maintain negative fluid balance     Chest pain Assessment & Plan Suspect secondary to cough, pneumonia Troponin negative Ddimer normal US left lower extremity negative for VTE   Morbid obesity (HCC) Assessment & Plan Nutrition consult   Pneumonia Assessment & Plan Small right effusion, adjacent airspace disease on CXR today - f/u imaging suggested Procalcitonin low Possibly related to COVID - will hold on adding antibiotics for now Treat for COVID             Subjective     HISTORY OF PRESENT ILLNESS: Patient is a 33 y.o. female who presents today with shortness of breath.   She complains of fever, chills, cough, chest pain, shortness of breath that began about 3 days ago (12/9).  The chest pain is central chest and increases with cough or shortness of breath - sometimes radiates to the back.     She was seen in an urgent care 12/6 secondary to left foot swelling and heart palpitations.  Her workup was negative.  She hasn't had any further heart palpitations since then.  She denies any history of PE or DVT.     She is vaccinated for COVID but hasn't had a booster.  She had the pfizer vaccine.      Patient Active Problem List Diagnosis ? Acute hypoxemic respiratory failure due to COVID-19 (HCC) ? Pneumonia ? Morbid obesity (HCC) ? Chest pain   Past medical, surgical, family and social history reviewed.     Medical HistoryExpand by Default History reviewed. No pertinent past medical history.   Past Surgical History Past Surgical History: Procedure Laterality Date ? HX TONSILLECTOMY         Social History     Socioeconomic History ? Marital status: Single     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Not on file Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used Vaping Use ? Vaping Use: Never used Substance and Sexual Activity ? Alcohol use: Yes     Comment: occasional glass of wine ? Drug use: Never ? Sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative   Lives with boyfriend.      Social Determinants of Health    Financial Resource Strain: Not on file Food Insecurity: Not on file Transportation Needs: Not on file Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Housing Stability: Not on file     Family History Family History Problem Relation Age of Onset ? Diabetes Maternal Grandfather   ? Heart Disease Paternal Grandfather   ? Kidney Failure Paternal Grandfather        Prescriptions Prior to Admission (Not in a hospital admission)   No Known Allergies Review of Systems Constitutional:  Positive for activity change, appetite change, fatigue and fever. Negative for chills.  HENT: Positive for rhinorrhea (resolved) and sore throat (resolved). Negative for congestion.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for sputum production.   Cardiovascular:  Positive for chest pain and palpitations. Negative for leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Positive for muscle pain. Negative for falls.  Neurological:  Positive for headaches and weakness. Negative for dizziness.  Skin:  Negative for rash.          Objective     OBJECTIVE: BP 147/83  | Pulse 95  | Temp 99.7 °F (37.6 °C) (Oral)  | Resp 28  | SpO2 94%    Physical Exam Vitals reviewed.  Constitutional:      Appearance: She is well-developed. She is obese. She is ill-appearing and diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: No oropharyngeal exudate.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing, rhonchi or rales.  Chest:     Chest wall: Tenderness (mild central) present.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No swelling or deformity.     Cervical back: Neck supple.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.     Findings: No rash.  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.   d/c summary: BRIEF OVERVIEW: Primary Care Provider at Discharge: None Physician, MD None Admission Date: 12/11/2021 Discharge Date: 12/13/2021   DISCHARGE DIAGNOSES: 1. Acute hypoxemic respiratory failure secondary to COVID-19 pneumonia 2. Pleuritic chest pain, secondary to #1 3. Morbid obesity   DISCHARGE DISPOSITION: Discharge to home   DISCHARGE CONDITION: Stable   FOLLOW-UP RECOMMENDATIONS: 1. Patient was recommended to follow-up with her PCP in 1 week.     No future appointments. Appointments Needing to be Scheduled Instructions for after discharge    Call the Doctor for Persistent Nausea or Vomiting   Complete by: As directed     Call the Doctor for Redness, Tenderness, or Signs of Infection at IV or Procedure Site(s)   Complete by: As directed     Call the Doctor for Severe Uncontrolled Pain   Complete by: As directed     Call the Doctor for Temperature Greater Than 100.3 F   Complete by: As directed     Call the Doctor if Red Blood Found in Stool or Vomit   Complete by: As directed     Do Not Smoke or Use Tobacco Products   Complete by: As directed     HOME OXYGEN   Complete by: As directed     Read New Medication Instructions   Complete by: As directed     Resume Normal Activity as Tolerated   Complete by: As directed     Resume Normal Diet   Complete by: As directed       DETAILS OF HOSPITAL STAY:   HOSPITAL COURSE: Patient is a 33-year-old female with history of morbid obesity who presented with chest pain and increased shortness of breath.  She is vaccinated against COVID-19.  In the ED, she was noted to be hypoxemic on room air, and was placed on 2 L oxygen.  Chest x-ray showed small right-sided pleural effusion and airspace disease vs consolidation in the right base.  Left lower extremity venous Doppler was obtained and was negative.  She tested positive for COVID-19.  She was admitted to the hospitalist service for further work-up and management.   Upon admission, she was started on Decadron 6 mg daily.  She was given Remdesivir x2 doses.  She was able to be weaned back to room air with rest, but continued to require 2 L oxygen with activity.  She felt improved by the morning of 12/13.   She was discharged home on 12/13/21.  She will be discharged home on 2 L oxygen with activity only.  She will be continued on 5 days of Decadron at discharge.  She should follow-up with her PCP in 1 week. She was instructed to return to the ED if her oxygen saturations drop below 89% and do not improve.   CONSULTS / RECOMMENDATION: None   INPATIENT PROCEDURES: None DISCHARGE MEDICATIONS: ? albuterol HFA (PROVENTIL HFA, VENTOLIN HFA, PROAIR HFA) 108 (90 Base) MCG/ACT inhaler Take 2 puffs by inhalation every 4 hours as needed for Wheezing. ? dexamethasone (DECADRON) 6 MG tablet Take 1 tablet by mouth daily for 5 days. ? guaiFENesin (MUCINEX) 600 MG 12 hr tablet Take 1 tablet by mouth 2 times daily for 7 days. ? naproxen (ALEVE) 220 MG tablet Take 440 mg by mouth 2 times daily as needed.