Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Back pain, Basophil count decreased, Basophil percentage decreased, Blood albumin decreased, Blood alkaline phosphatase normal
Clinical narrative: Hospitalized (12.29.21 - 12.31.21); COVID-19 positive (12.29.21); Fully vaccinated  - J&J x1  D/c Summary: Discharge Summary (Physician) General Medicine BRIEF OVERVIEW Admission Date: 12/29/2021 Discharge Date: Dec 31, 2021    Active Hospital Problems   Diagnosis Date Noted POA ? Type 2 diabetes mellitus without complication, without long-term current use of insulin 12/29/2021 Unknown ? Essential hypertension 12/29/2021 Unknown   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Pneumonia due to COVID-19 virus 12/29/2021 12/31/2021 Yes   There are no active non-hospital problems to display for this patient.     Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:    There was possible small chronic DVT seen on her venous ultrasound. No follow up indicated at this time unless further symptoms develop.     DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia Pneumonia due to COVID-19 virus COVID-1   HOSPITAL COURSE: 67 y/o vaccinated female hx of DM2 and hypertension who presented with COVID 19. She was briefly hypoxic in the ER requiring oxygen via NC but weaned quickly to RA after admission. She did have some chest and arm pain with elevated D dimer so CT angio was obtained that showed no PE. She also had some calf pain so b/l lower extremity venous u/s was obtained and showed no acute DVT (possible small chronic DVT seen). No anticoagulation was indicated. She was feeling well and maintained with no further oxygen needs. She was discharged to home in stable condition.    CONSULTS / RECOMMENDATION:  Consult Orders (From admission, onward)   None     INPATIENT PROCEDURES:  Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP 140/87  | Pulse 62  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.676 m  | Wt 65.8 kg  | SpO2 97%  | BMI 23.40 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress. HENT:     Head: Normocephalic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness.  Skin:    Findings: No rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Behavior: Behavior normal  H&P: Admission History and Physical    CHIEF COMPLAINT cough     Assessment/Plan    ASSESSMENT Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC)   Essential hypertension     PLAN   Covid pneumonia Symptom onset: 12/25 Covid + 12/29 Vaccinated 3/17 with J&J  CXR: bilateral patchy lower lung pneumonia c/w Covid -19 O2 Sat 87% on ambulation in ED Decadron 6 mg PO x 10 days Daily covid labs Continuous pulse oximetry Prone as tolerated/ IS Consider remdesevir as patient willing to accept if medical team feels her condition warrants it   DM type 2 Hgb A1C = 6.8 in September On metformin - HOLD 24 hour corrective insulin Monitor BG and adjust as needed, likely will need increase regimen with steroids   Essential hypertension BP elevated in ED, has not taken meds in a few days Continue home amlodipine-benazapril (sub with lisinopril)   HLD Continue statin (reports she is noncompliant with this)   OSA Does not tolerate mask due to claustrophobia   Chronic pain Home norco prn   Diet:  Diabetic  VTE Prophylaxis:  Lovenox Subq Code status: FULL    Above assessment and plan discussed with Dr. whose insight is reflected above.       Subjective    HISTORY OF PRESENT ILLNESS Patient is a 67 y.o. female with past medical history significant for DM type 2, hypertension, and hyperlipidemia who presented to ED with cough and shortness of breath. Patient reports symptoms of fever, chills, body aches, cough and shortness of breath began on 12/25. She has also had vomiting and diarrhea and has not been able to keep medications down for the last few days. She reports a productive cough of blood-tinged sputum. She denies any chest pain, urinary symptoms, or falls at home. She is vaccinated having received 1 dose of the J&J vaccine on 3/17/21.    In the ED, she was afebrile, HR 77, RR 16, BP elevated reaching 178/114, and oxygen saturation 98% on room air. She did have a desaturation to 87% while ambulating in ED. Chest x-rays showed bilateral patchy lower lung pneumonia c/w Covid -19. Labs were unremarkable. Covid testing was positive. She received albuterol inhaler, decadron 6 mg IV, and zofran in ED. She is being transferred to Blodgett Hospital for further evaluation and management.      Patient Active Problem List Diagnosis ? Pneumonia due to COVID-19 virus ? Type 2 diabetes mellitus without complication, without long-term current use of insulin ? Essential hypertension REVIEW OF SYSTEMS Review of Systems  Constitutional: Positive for appetite change, chills and fever. Negative for diaphoresis.  HENT: Negative for sore throat and trouble swallowing.   Eyes: Negative for photophobia and visual disturbance.  Respiratory: Positive for cough and shortness of breath.   Cardiovascular: Negative for chest pain and leg swelling.  Gastrointestinal: Positive for diarrhea, nausea and vomiting. Negative for abdominal pain and constipation.  Endocrine: Negative for polydipsia, polyphagia and polyuria.  Genitourinary: Negative for difficulty urinating, dysuria, frequency and urgency.  Musculoskeletal: Positive for back pain and myalgias.  Skin: Negative for rash and wound.  Neurological: Negative for dizziness, light-headedness and numbness.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative for confusion and hallucinations.            Objective    OBJECTIVE BP 165/98  | Pulse 78  | Temp 98.8 °F (37.1 °C) (Oral)  | Resp 22  | Wt 68 kg (150 lb)  | SpO2 97%  | BMI 24.21 kg/m²  Physical Exam Constitutional:      General: She is not in acute distress. HENT:     Head: Normocephalic.     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.     Comments: Clear anteriorly , diminished posteriorly Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Normal range of motion.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  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.