Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Decreased appetite, Differential white blood cell count, Dizziness postural, Dyspnoea, Ear pain
Clinical narrative: Hospitalized (12.17.21 - 12.21.21); COVID-19 positive (12..17.21); Fully vaccinated PLUS Booster - moderna d/c summary: Local HOSPITAL  Discharge Summary   BRIEF OVERVIEW: Discharge Provider: (NAME), DO Primary Care Provider at Discharge: (NAME), DO  Admission Date: 12/17/2021 Discharge Date: 12/21/2021  Discharge Disposition: Home    Code Status: DNR     DISCHARGE DIAGNOSIS: 1. Sepsis 2/2 COVID-19 PNA (resolved) 2. Acute Hypoxic Respiratory Failure (resolved) 3. Chest Pain (resolved) 4. HTN 5. HLD 6. GERD 7. Pre-diabetes 8. Migraines     DISCHARGE MEDICATIONS: See changes in bold ? [START ON 12/22/2021] dexamethasone (DECADRON) 6 MG tablet Take 1 tablet by mouth daily for 6 days. ? furosemide (LASIX) 20 MG tablet Take 1 tablet by mouth at 6:00 p.m. daily for diuretic ? omeprazole (PRILOSEC) 20 MG delayed release capsule take 1 capsule by mouth twice a day ? oxybutynin ER (DITROPAN XL) 15 MG 24 hr tablet take 1 tablet by mouth once daily ? rosuvastatin (CRESTOR) 5 MG tablet Take 1 tablet by mouth daily. For cholesterol     FOLLOW-UP RECOMMENDATIONS: 1) PCP for post-hospitalization follow-up. Concern for OSA, may need sleep study referral. Pre-diabetic (A1c 5.9%).   Future Appointments Date Time Provider Department Center 11/14/2022  9:00 AM (NAME), DO HCF HCF ID #   Appointments Needing to be Scheduled Contact information for follow-up     (NAME) DO Specialty: Family Medicine and OMT Relationship: PCP - General PCP -  HCF (PRIVACY)    Next Steps: Schedule an appointment as soon as possible for a visit in 1 week(s)       DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Shortness of breath   HOSPITAL COURSE: Patient is a 79 year-old female who was admitted on 12/17/2021 for COVID-19 pneumonia with acute hypoxia.  Patient is vaccinated and had just received her booster 1 week ago.  She was initially requiring 2 L of oxygen.  She had been 7 days of symptoms but was given remdesivir and completed course.  Started on Decadron receive 4 days at discharge will continue for 6 more days.  Patient has been weaned to room air for 2 days.  Today her ambulatory pulse ox was 93%.  Patient feels very much so improved and is anxious to go home as her husband is sick with COVID as well.  Still continues to have a slight nonproductive cough. Discussed signs and symptoms of post COVID complications such as PE and DVT, prolonged fatigue.  Education handouts given on these for signs and symptoms to watch out for. D-dimer today 930 and CRP 17.4. Leukocytosis down to 11.82 from 14.35 (most likely steroid induced).   Vitals are stable patient is medically cleared for discharge.   Physical Exam at Discharge Enc Vitals BP: 109/67 Pulse: 78 Respirations: 16 Temperature: 36.8 °C Temp src: Oral SpO2: 93 % Weight: 87.4 kg Height: 167.6 cm Room air   Physical Exam Constitutional: Well nourished, no acute distress. Alert and oriented to person, place and time. Answering questions appropriately. Cardiovascular: Normal rate and regular rhythm. Good peripheral perfusion. Pulmonary/Chest: Unlabored speech and respirations on room air. No use of accessory muscles. Clear lung sounds. Intermittent dry cough. Musculoskeletal: Moving all four extremities spontaneously. Steady gait, ambulating throughout the room. Integumentary: Warm, pink, and dry.  Neurological: No gross motor or sensory deficits.   H&P: CHIEF COMPLAINT: Covid 19   Subjective      HISTORY OF PRESENT ILLNESS: 79 year old female who presents with covid pneumonia.   79-year-old female who presents with COVID 19 pneumonia.  Patient presented to the emergency department after 7 days of worsening shortness of breath.  Patient initially came to the emergency department for evaluation for monoclonal antibodies was found to be hypoxic in the low 80s.  Patient was placed on 2 L nasal cannula which improved her oxygen saturations.  Hospitalist service was asked to admit patient for further management of her COVID-19 pneumonia.   At the time of this providers exam patient is resting queitly in ED.  Patient got modera booster last Friday on December 10.  Patient had initial modera series in June 2021. However after booster last week patient felt fatigued, productive cough (non-bloody, non-coffee grounds), body aches, headaches, rib pain from coughing, chills, chest pain with coughing on left,    Left arm is sore from where patient received booster.   No shortness of breath currently.  No home o2.   Patient states that yesterday she stood up, was dizzy, then tripped over dogs.  Patient states she caught herself on the wall and was able to stand right back up.  Patient denies any prolonged down time, head injury, or syncope.    Poor appetite, decreased PO intake, nausea.    Headahces ongoing for 7 days with associated left ear pain and ringing.  No reported head injury.  Different from normal migraine pattern.  Hurts primarily on the left side rates as a 7/10.  Taking ibuproben-taking 2x a day with no improvment.  Also associated left neck pain.  No pain with mastication.     Chest pain is on left side, with coughing.  Resolves when not coughing. No radiation of chest pain.   Patient denies dyspnea,  head injury, syncope, abdominal pain, vomiting, constipation, diarrhea, dysuria,  numbness, tingling, one-sided weakness, vision changes, slurred speech, facial drop, skin rashes, homicidal thoughts or suicidal thoughts.     Emergency department course: Tylenol, Tessalon Perles, Decadron, 1 L normal saline, Review of Systems Constitutional:  Positive for chills. Negative for fever.  HENT: Negative for congestion.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough. Negative for shortness of breath.   Cardiovascular:  Positive for chest pain.  Gastrointestinal:  Positive for nausea. Negative for vomiting, abdominal pain, constipation and diarrhea.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Positive for falls.  Neurological:  Positive for headaches. Negative for numbness/tingling.  Psychiatric/Behavioral:  Negative for behavioral problems.  Skin:  Negative for new spots.              Objective    OBJECTIVE: BP 153/69  | Pulse 89  | Temp 100.2 °F (37.9 °C) (Oral)  | Resp 19  | Wt 85.7 kg (189 lb)  | SpO2 95%  | BMI 30.51 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is ill-appearing. She is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Left Ear: Tympanic membrane, ear canal and external ear normal. There is no impacted cerumen.     Ears:     Comments: No pain or redness on left extremal ear.  No left mastoids process tenderness.    Mouth/Throat:     Mouth: Mucous membranes are dry.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Comments: No lower extremity edema Pulmonary:     Comments: Diminished lung sounds in all posterior fields with scattered expiratory wheezes.  Patient able to talk to provider in full sentences without becoming short of breath.  95% on 2L NC. 18 BPM while provider in room. No retractions or acute respiratory distress.  Dry cough while provider in room Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.     Sensory: No sensory deficit.     Motor: No weakness.     Gait: Gait normal.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.