Age: 49.0
Sex: F
Vaccine: COVID19
Symptoms: Lung opacity, Mean cell volume normal, Nausea, Obesity, Oedema
Clinical narrative: ED to Hosp-Admission Discharged   7/14/2022 - 7/18/2022 (4 days) HOSPITAL   MD  Last attending ? Treatment team Acute respiratory failure with hypoxemia  Principal problem   Discharge Summary MD (Physician) ? ? Hospitalist     DISCHARGE SUMMARY:   MRN: Name: Age: 50 y.o. Admit Date: 7/14/2022  3:13 PM Discharge Date:  7/18/2022 Admitting Physician: Dr.  Discharge Physician: MD   Discharge Diagnosis: Principal Problem:   Acute respiratory failure with hypoxemia Active Problems:   HOCM (hypertrophic obstructive cardiomyopathy)   Pulmonary infiltrates   Environmental allergies   Antiphospholipid antibody syndrome   AICD (automatic cardioverter/defibrillator) present        HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 50 y.o. female with a history below admitted for Acute respiratory failure with hypoxemia. Pt came in with complaints of sob, worse with exertion, chest tightness. associated chest tightness. Was treated as bronchitis several weeks prior, no improvement, gradual worsening. No leg swelling, signs of clot. Negative for covid at that time, now positive. Discussed with er and will admit "   Hospital Course: Patient, is a 50 y.o. female who presented with SOA. She was managed for the following:   * Acute respiratory failure with hypoxemia Description of the Problem/Progression: New. Also asthma exacerbation. O2 61. Appears had previous hypoxia 3/22, treated as pneumonia and improved. This admission + for COVID, no infiltrates on ct. Hx of SLE and asthma .  Plan:  - Remdesivir  - pulm consult  - O2 per protocol  - nebs prn - decadron - bid given  - lovenox  - Rocephin / azithro  - vitamins - pepcid - melatonin  - Incentive spirometry  - Prone pt as able   SLE - hold plaquenil                Physical Exam on the Date of Discharge: Blood pressure 124/62, pulse 82, temperature 98 °F (36.7 °C), temperature source Skin, resp. rate 17, height 5' 3" (160 cm), weight 102.2 kg (225 lb 3.2 oz), last menstrual period 10/10/2010, SpO2 98 %. General - NAD, appears stated age, obese, pleasant HEENT - EOMI, PER, MMM, oropharynx clear Chest - no w/r/r, normal effort Heart - RRR,  Abdomen - Soft, non-tender,  Extremities - warm, no edema Psych - AAOx3, affect appropriate Skin - no rash, dry   Discharge Condition: improved   Disposition:home    CONSULTS DURING ADMISSION:  IP CONSULT TO PULMONOLOGY    IMAGING / PROCEDURES / RESULTS:     XR Chest PA And Lateral   Result Date: 7/13/2022                                                                 Radiology  PATIENT NAME:             MR#:  PROCEDURE DATE:  07/13/2022                       ACCOUNT#: ACCESSION #:                      ROOM#: ORDERING PHYS:  Persistent cough  Chest 2 views compared with 03/10/2022  Findings:  Normal cardiomediastinal silhouette and unchanged AICD.  Minimal to mild chronic prominence of pulmonary vasculature is redemonstrated.  Right perihilar platelet atelectasis or scarring noted.  No evidence of segmental infiltrate, consolidation or effusion.  IMPRESSION:  Interval mild right perihilar platelet atelectasis or scarring. Otherwise stable.               THIS IS AN ELECTRONICALLY VERIFIED REPORT             7/13/2022 8:28 AM:   MD    MD  DD:  07/13/2022 TD:  07/13/2022 JOB #:                                    Radiology Page 1    of   1                                                          COPY   CT Thorax WO   Result Date: 7/14/2022                                                Radiology  PATIENT NAME:                 MR#:  PROCEDURE DATE:  07/14/2022                       ACCOUNT#:  ACCESSION #:                          ROOM#:  ORDERING PHYS:   CLINICAL HISTORY: Cough, hemoptysis.Additonal clinical history pertaining to current exam: None available.  CT scan of the chest without contrast.  Technique: Helical imaging through the chest without IV contrast, followed by multiplanar reconstruction.  Axial 5 mm, sagittal and coronal 3 mm slice thickness images are submitted for interpretation. Radiation dose reduction techniques utilized. Comparison Study: 322.  FINDINGS: Evaluation of hilum is limited in absence of IV contrast. Stable mediastinal contents including the central vascular structures, central airway, subcentimeter mediastinal lymph nodes as well as low density 2.6 x 3.7 cm lesion at the anterior aspect of the aortic arch.  No enlarged axillary lymphadenopathy.  Largest mediastinal lymph node measures 9.5 mm without change.  No evidence of pleural or pericardial effusion.  Limited noncontrast images of the upper abdomen are stable without acute finding.  Scattered areas of atelectasis/scarring in the mid and lower lungs are redemonstrated.  Scattered areas of ground-glass opacities involving all lungs are also similar to the previous examination.  No evidence of segmental infiltrate or consolidation.  No discrete nodule is identified by me or CAD report.  Stable osseous structures without demonstration of osseous destructive changes.  IMPRESSION:  Essentially stable examination with chronic changes as described.  No new acute finding. This note is generated using voice recognition computer software. Inadverent errors  may have  occurred  while dictating note.  Common sense approach is appreciated.               THIS IS AN ELECTRONICALLY VERIFIED REPORT             7/14/2022 4:57 PM:   MD    MD  DD:  07/14/2022 TD:  07/14/2022 JOB #:                                    Radiology Page 1    of   1                                                          COPY   XR Portable Chest   Result Date: 7/16/2022                                                          Radiology  PATIENT NAME:                  MR#:  PROCEDURE DATE:  07/16/2022                       ACCOUNT#:  ACCESSION #:                            ROOM#:  ORDERING PHYS:  MD  Single view chest  History:  Respiratory failure  Comparison is made with 07/13/2022.  Lung inspiration is shallow.  Increasing perihilar and basilar linear air space disease.  The remainder of the examination is similar.  Impression:  Increasing perihilar and basilar linear air space disease either related to worsening atelectasis or pneumonia.               THIS IS AN ELECTRONICALLY VERIFIED REPORT              7/16/2022 6:20 AM:  MD   MD  DD:  07/16/2022 TD:  07/16/2022 JOB #:                                  Radiology Page 1    of   1                                                          COPY            LABS AT TIME OF DISCHARGE:    Lab Results Component Value Date   WBC 8.7 07/18/2022   HGB 12.7 07/18/2022   HCT 38.4 07/18/2022   MCV 83.0 07/18/2022      Lab Results Component Value Date   SODIUM 136 07/18/2022   POTASSIUM 4.7 07/18/2022   MAGNESIUM 1.9 09/20/2020   CHLORIDE 103 07/18/2022   CO2 25 07/18/2022   GLUCOSE 136 (H) 07/18/2022   BUN 18 07/18/2022   CREATININE 0.7 07/18/2022   CALCIUM 9.3 07/18/2022   TBILIRUBIN 0.2 07/18/2022   DBILIRUBIN 0.1 04/28/2010   ALP 46 07/18/2022   AST 9 (L) 07/18/2022   ALBUMIN 3.7 07/18/2022      Lab Results Component Value Date   INR 1.0 03/08/2022   INR 1.0 09/20/2020      Microbiology Results (last 14 days)    Procedure Component Value Units Date/Time   Blood Culture Collected: 07/14/22 1545   Order Status: Completed Specimen: Blood from Vein Updated: 07/17/22 1800     BLOOD CULTURE --     No growth @ 24 hours. No growth @ 48 hours. No growth @ 72 hours.     Blood Culture Collected: 07/14/22 1545   Order Status: Completed Specimen: Blood from Vein Updated: 07/17/22 1800     BLOOD CULTURE --     No growth @ 24 hours. No growth @ 48 hours. No growth @ 72 hours.     SARS-CoV-2, QL, PCR (STAT)   (Abnormal) Collected: 07/14/22 1537   Order Status: Completed Specimen: Nasopharyngeal from Nasophayngeal Updated: 07/14/22 1654     SARS-CoV-2 RNA Detected      Comment:   Reference value:  Undetected   Testing was performed using the System.   Fact sheets for this Emergency Use Authorization (EUA) assay can be found at the following links:        Test Performed by: Lab Director: D.O.      Narrative:     Symptomatic?->No Indications (select all that apply)->Admission Called to and read back at 16:54 on 07/14/2022,          MEDICATIONS AND ORDERS    Current Discharge Medication List   START taking these medications   Details dexAMETHasone (DECADRON) 4 mg tablet Take 1 Tablet by mouth Once Daily for 3 days, THEN 0.5 Tabs Once Daily for 3 days. Qty: 5 Tablet, Refills: 0   Associated Diagnoses: Pulmonary infiltrates; Acute respiratory failure with hypoxemia     CONTINUE these medications which have NOT CHANGED   Details guaiFENesin (MUCINEX) 600 mg Take 600 mg by mouth Every 12 hours.   Benzonatate (TESSALON PERLES) 200 mg capsule Take 1 Capsule by mouth Three times a day. Qty: 30 Capsule, Refills: 0   Associated Diagnoses: Cough   hydrOXYchloroQUINE (PLAQUENIL) 200 mg tablet Take 2 Tabs by mouth At bedtime for 90 days. Qty: 180 Tablet, Refills: 0   Associated Diagnoses: Other forms of systemic lupus erythematosus, unspecified organ involvement status; Antiphospholipid antibody syndrome   pregabalin (LYRICA) 25 mg Take 1 Capsule by mouth Twice a day. Qty: 60 Capsule, Refills: 1   Associated Diagnoses: Idiopathic progressive polyneuropathy; Fibromyalgia; Numbness in both legs   ergocalciferol (VITAMIN D2) 50,000 unit CAPSULE Take 1 Capsule by mouth Every week. Qty: 12 Capsule, Refills: 3   Associated Diagnoses: Vitamin D deficiency   pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 2   Associated Diagnoses: Gastroesophageal reflux disease without esophagitis   levocetirizine (XYZAL) 5 mg tablet Take 5 mg by mouth Once Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Sinus drainage   metoprolol (TOPROL-XL) 25 mg XL tablet Take 1 Tablet by mouth Daily. Qty: 30 Tablet, Refills: 11   Associated Diagnoses: Primary hypertension   albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler Take 2 Puffs by inhalation Every 4 hours as needed (WHEEZING). Qty: 2 Each, Refills: 5   Associated Diagnoses: Wheezing   OXcarbazepine (TRILEPTAL) 150 mg Take 2 Tabs by mouth Twice a day. Qty: 120 Tablet, Refills: 3   Associated Diagnoses: Complex regional pain syndrome i of left lower limb; Idiopathic progressive polyneuropathy   fluticasone propionate (FLONASE) 50 mcg/Actuation nasal spray Spray 2 Sprays in nose Daily. (in each nostril) Qty: 1 Each, Refills: 5   Associated Diagnoses: Chronic pansinusitis   cyanocobalamin (VITAMIN B-12) 1,000 mcg tablet Take 1 Tablet by mouth Daily. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: B12 deficiency   promethazine (PHENERGAN) 25 mg tablet Take 1 Tablet by mouth EVERY 6 TO 8 HOURS PRN for Nausea. Qty: 30 Tablet, Refills: 2   Associated Diagnoses: Nausea   busPIRone (BUSPAR) 10 mg tablet Take 10 mg by mouth Twice a day.   -NONFORMULARY/HELP MEDICATION- CBD oil 1000 mg prn   Meloxicam (MOBIC) 15 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 2   Associated Diagnoses: Osteoarthritis of multiple joints, unspecified osteoarthritis type   aspirin (ASPIRIN) 81 mg DR tablet Take 81 mg by mouth Daily.   DULoxetine (CYMBALTA) 60 mg DR capsule Take 2 Caps by mouth Daily. Qty: 180 Cap, Refills: 1   Associated Diagnoses: Sleep disturbance   traZODone (DESYREL) 100 mg tablet Take 2 Tabs by mouth At bedtime. Qty: 180 Tab, Refills: 1   Associated Diagnoses: Sleep disturbance   calcium carbonate (TUMS) 200 mg calcium (500 mg) tablet Take 1 Tab by mouth As needed.   hydrocortisone 0.5 % cream by Topical route Twice a day. Indications: Inflammation of Skin caused by an Allergy   furosemide (LASIX) 20 mg tablet Take 1 Tab by mouth As directed. As needed for swelling Qty: 30 Tab, Refills: 3   Associated Diagnoses: Edema, unspecified type   acetaminophen (TYLENOL) 325 mg tablet Take 2 Tabs by mouth Every 4 hours as needed for Pain and Fever. Refills: 0   aspirin-acetaminophen-caffeine (EXCEDRIN MIGRAINE) 250-250-65 mg Take 1 Tablet by mouth Every 6 hours as needed. headaches   methocarbamoL (ROBAXIN) 750 mg tablet Take 1 Tab by mouth Three times a day. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Complex regional pain syndrome i of left lower limb; Idiopathic progressive polyneuropathy     STOP taking these medications     predniSONE (DELTASONE) 20 mg tablet Comments:  Reason for Stopping:        doxycycline monohydrate (MONODOX) 100 mg capsule Comments:  Reason for Stopping:             Discharge Procedure Orders Home Oxygen    Order Specific Question Answer Comments Liters per minute: 2 LPM      Follow up with your PCP,    Order Specific Question Answer Comments Follow up when? 1 week      Follow-Up with Pulmonary; 1 week    Order Specific Question Answer Comments Follow up with whom? Pulmonary   Follow up when? 1 week        PCP PCP:  APRN     Future Appointments Date Time Provider Department Center 7/29/2022 11:30 AM MD  Facility Fee 8/4/2022  3:00 PM APRN None 1/6/2023  2:00 PM CLINIC CARDA None   ----   Greater than 30 minutes was spent on discharging this patient.   Signed,  MD       Other Notes All notes   H&P from MD (Hospitalist)    Consults from MD (Pulmonology)       Hospital Problem List   Environmental allergies  Antiphospholipid antibody syndrome  AICD (automatic cardioverter/defibrillator) present  HOCM (hypertrophic obstructive cardiomyopathy)  Acute respiratory failure with hypoxemia  Pulmonary infiltrates   Care Timeline   07/14   Admitted from ED 2218 07/18   Discharged 2248   Discharge   Home or Self Care     IP After Visit Summary (Printed 7/18/2022)    Follow-Ups  1 Follow up with APRN (Family Medicine) 2 Follow up with APRN (Family Medicine) 3 Follow up with MD (Urology) 4     Medication List at Discharge   -NONFORMULARY/HELP MEDICATION- CBD oil 1000 mg prn  acetaminophen 650 mg EVERY 4 HOURS PRN  albuterol sulfate 90 mcg/Actuation 2 Puffs Inhalation EVERY 4 HOURS PRN  aspirin 81 mg Oral DAILY  aspirin/acetaminophen/caffeine 250-250-65 mg 1 Tablet Oral EVERY 6 HOURS PRN, headaches  benzonatate 200 mg Oral THREE TIMES A DAY  buspirone HCl 10 mg Oral TWICE A DAY  calcium carbonate 200 mg calcium (500 mg) 1 Tablet Oral PRN  cyanocobalamin (vitamin B-12) 1,000 mcg Oral DAILY  dexamethasone 4 mg Take 1 Tablet by mouth Once Daily for 3 days, THEN 0.5 Tabs Once Daily for 3 days.  duloxetine HCl 120 mg Oral DAILY  ergocalciferol (vitamin D2) 50,000 Units Oral EVERY WEEK  Patient taking differently:  Take 50,000 Units by mouth Every week. Patient takes once a week on Monday  fluticasone propionate 50 mcg/Actuation 2 Sprays Nasal DAILY, (in each nostril)   furosemide 20 mg Oral AS DIRECTED, As needed for swelling  guaifenesin 600 mg Oral EVERY 12 HOURS  hydrocortisone 0.5 % Topical TWICE A DAY  hydroxychloroquine sulfate 400 mg Oral AT BEDTIME  levocetirizine dihydrochloride 5 mg Oral DAILY  meloxicam 15 mg Oral DAILY  methocarbamol 750 mg Oral THREE TIMES A DAY  metoprolol succinate 25 mg Oral DAILY  oxcarbazepine 300 mg Oral TWICE A DAY  pantoprazole sodium 40 mg Oral DAILY  pregabalin 25 mg Oral TWICE A DAY  promethazine HCl 25 mg Oral EVERY 6 TO 8 HOURS PRN  trazodone HCl 200 mg Oral AT BEDTIME    Additional Orders and Documentation   Results Imaging EKG Microbiology Labs   Meds    Orders Procedures Nursing   Flowsheets  Forms: IP SEVERE SEPSIS SCREENING  Encounter Info: History, Allergies, Detailed Report, Care Plan, Billing    Communications   Summary of Care Document sent to APRN  Sent 7/14/2022 by DO   Media From this encounter Scan on 7/25/2022: Paper chart Scan on 7/20/2022: telemetry strips Scan on 7/16/2022 Electronic signature on 7/14/2022 1557 - E-signed Scan on 7/18/2022 1040 by  Scan on 7/14/2022: Perceptive Content Scan Scan on 7/14/2022 2128 by   Isolation  No Isolation   Patient Demographics  Patient Name   Legal Sex  Female DOB    Durable Medical Equipment Communication History  Coordination has not been started for this encounter.  Community Resources Communication History  Coordination has not been started for this encounter.  HOME HEALTH CARE Communication History  Coordination has not been started for this encounter.  DIALYSIS OR INFUSION Communication History  Coordination has not been started for this encounter.  Destination Communication History  Coordination has not been started for this encounter.  COMMUNITY RESOURCE Communication History  Coordination has not been started for this encounter.   Payor Communication History   Document Sent Status Last Sent First Sent Sent By Fax Notes - Discharge Summary Completed 7/19/2022 08:49 ?  Full Report - Adm + UR (Last) Completed 7/15/2022 13:48 ? RN