Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Chronic kidney disease, Computerised tomogram abdomen normal, Culture urine, Dyspnoea
Clinical narrative: Date of Admission:  9/9/2023   Date of Discharge:  9/10/2023    Issues to be Addressed on followup with PCP:   Follow up for any development of SOB as you have been diagnosed with COVID   Reason for Hospitalization: COVID 19   Significant Findings: COVID 19 positive   Diagnoses:   Active Hospital Problems   Diagnosis   ? (Principal) SEPSIS WO ACUTE ORGAN DYSFUNCTION   ? COVID-19 DISEASE   ? POLYMYALGIA RHEUMATICA   ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION   ? CKD STAGE 3A (GFR 45-59)   ? HYPOTHYROIDISM   ? HTN (HYPERTENSION)     Resolved Hospital Problems   Diagnosis Date Resolved ? UTI (URINARY TRACT INFECTION) 09/09/2023     Consults:  None    Primary Procedures:  None    Complications:  none    Hospital Course:    The patient is a pleasant 83 year old female with a medical history significant for polymyalgia rheumatica on prednsione (follows with Dr. rheumatology-last TAV on 8/7/2023), hypothyroidism on synthroid (TSH 5.1 on 10/2022), depression on Cymbalta, and HTN on losartan with CKD stage 3A (GFR 56 pm 2/15/2022, serum creatinine 0.94 on 2/2022, 1.23 on 7/28) who was admitted for fevers/chills, found to have COVID 19.   Patient did not require any O2 supplementation.  CXR with no bilateral opacities, no pulmonary edema. CT abdomen/pelvis with IV contrast->no signs of infection (gallstones with no evidence of cholecystitis).  UA with only 19 WBCS, but large LE.   Patient with no dysuria.  Source of fevers and chills likely COVID 19.   Given 200 mg RDV x 1 for COVID.   Also given rocephin 1 gram x 1.   Will dc with 5 days of Paxlovid. Patient with no issues on dc.  No SOB.  NO chest pain.  Labs only notable for mildly elevated CRP of 8.1 Also gave three day prescription for cefadroxil for presumed UTI.     Exam date 9/10/2023   S:   Feels well.   No chest pain, SOB, no fevers or chills   O:   Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery 09/10/23 0047 98.5 °F (36.9 °C) Oral 77 161/123 18 97 % RA 09/09/23 1749 98.2 °F (36.8 °C) Oral 101 132/57 18 93 % RA 09/09/23 1700 ? ? 114 139/83 18 93 % RA 09/09/23 1600 ? ? 108 148/89 20 94 % RA 09/09/23 1505 ? ? 104 153/69 16 95 % RA 09/09/23 1415 100.7 °F (38.2 °C) Oral ? ? ? ? ? 09/09/23 1227 100 °F (37.8 °C) Temporal Artery Scan 96 197/69 18 97 % RA     Exam: Gen: Alert and oriented x 3, NAD Lungs: CTA B CV: S1, S2, regular rate and rhythm Abdomen: normal active bowel sounds, NTTP, nondistended Extremities: no lower extremity edema     Condition on Discharge:  stable    Code Status : Full Code    Discharge Disposition:  Home    Pending Results:  Urine and blood cultures from 9/9/2023   Medications:  See discharge instructions for discharge medications     Discharge Instructions/Orders    ACTIVITIES/LIFESTYLE    Activities:    Don'ts: Please quarantine for at least 5 days from 9/9/2023 because of your COVID diagnosis    WOUND CARE  Not applicable.    DIET/NUTRITION  Diet: low salt    Seek medical attention for: Temperature of 100.4 degrees F or above  Pain unrelieved by medication  Persistent nausea/vomiting and/or inability to eat    Increase in fatigue, confusion or dizziness  Chest pain Shortness of breath Bleeding    FOLLOW UP APPOINTMENTS:    Appointment with your Primary Care Provider DO, in 1-2 weeks.    Review your medications with your doctor to see if there are any changes.   The following referrals have been made:  none        Note Details  Author (M.D.) File Time 9/10/2023 11:22 AM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/9/2023  ED to Hosp-Admission (Discharged) on 9/9/2023  ED to Hosp-Admission (Discharged) on 9/9/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HTN (HYPERTENSION)  HYPOTHYROIDISM  CKD STAGE 3A (GFR 45-59)  MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION  POLYMYALGIA RHEUMATICA  COVID-19 DISEASE  SEPSIS WO ACUTE ORGAN DYSFUNCTION Resolved  UTI (URINARY TRACT INFECTION) Resolved Care Timeline  09/09   Admitted from ED (Observation) 1725 09/10   Discharged 1312  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 9/10/2023) Medication List at Discharge   alendronate sodium 70 mg Oral WEEKLY, in the morning with 8 ounces of plain water at least one-half hour before the first food, drink, or other medication of the day. Do not lie down for at least one-half hour after swallowing this medication  Patient not taking:  Reported on 9/9/2023  cefadroxil 500 mg Oral 2 TIMES A DAY  cholecalciferol (vitamin D3) 25 mcg Oral DAILY  clonazepam 1 mg Take 1 tablet by mouth daily at bedtime. Must last 28 days  duloxetine HCl 20 mg Oral DAILY  Patient not taking:  Reported on 9/9/2023  gabapentin 100 mg Oral EVERY BEDTIME  ipratropium bromide 21 mcg (0.03 %) 2 Sprays Each nostril 2 TIMES A DAY  levothyroxine sodium 100 mcg Oral DAILY BEFORE BREAKFAST  losartan potassium 100 mg Oral DAILY  naloxone HCl 4 mg/actuation For Recipient Use. Use 1 Spray in one nostril. Seek immediate emergency medical help. If response is not obtained after 2 or 3 minutes, administer 2nd dose using new device in other nostril until emergency help arrives. Emergency use only  nirmatrelvir/ritonavir 150-100 mg Take 150 mg Nirmatrelvir (1 of 150 mg tablet) with 100 mg Ritonavir (1 of 100 mg tablet) by mouth 2 times a day for 5 days  polyethylene glycol 3350 17 gram/dose Mix 17 Grams in 4 to 8 ounces of water or juice and drink by mouth daily as directed for constipation  prednisone   5 mg Oral EVERY MORNING WITH A MEAL  1 mg Tab, Take 4 tablets by mouth every morning with a meal for 30 days, then 3 tablets every morning with a meal for 30 days, then 2 tablets every morning with a meal for 30 days, then 1 tablet every morning with a meal. Take with 5 mg tablets for the following taper 9 mg for 1 month then 8 mg for 1 month then 7 mg for 1 month then 6 mg for 1 month etc.  sucralfate 1 g Oral 4 TIMES A DAY  trazodone HCl 150 mg Oral EVERY BEDTIME  Patient not taking:  Reported on 9/9/2023