Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Lung infiltration, Oropharyngeal pain, Pleural effusion, Pyrexia, SARS-CoV-2 test positive
Clinical narrative: DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Severe sepsis (HCC) [A41.9, R65.20] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE:  admission H and P: The patient is a 66 y.o. female who presents today with cough and shortness of breath.  She has a history of MS and is bedbound.  Her son lives with her and is her caretaker.    She complains of about 4 days of cough, shortness of breath, fatigue, sore throat, and fever.  Her appetite is poor and her oral intake is decreased.  She notes decreased urine output that appears concentrated in her chronic foley catheter.  She was found to be positive for COVID in the ER, requiring 3 L of oxygen.    The patient is vaccinated for COVID and received her booster about a week ago.    She denies history of lung disease.                Following admission initiated and received total of x4 day treatment with decadron and Remdesivir therapy for tx of covid infection. O2 was able to be weaned to 2 l nc . She was evaluated for home oxygen and qualified for home use that was set up . Identified stage 2 pressure ulcers and was evaluated by out wound care team with rec for every other day and prn dressing changes with foam Ag with adhesive borders . also advised in doing routine side to side tilting in bed, and not to lay flat supine. Advised to follow up with wound clinic where she has been going plus in-home nursing and home dressing changes as before  . hhc rn set up to see in home . She was advised as to new diagnosis of diabetes of long standing with hgb a1 c level of 11.5 . She was started on basal lantus in the hospital and receiving 10 units nightly . At time of dc she was refusing to take insulin at home or check her blood glucose . Strongly advise to follow up with pcp for further discussions for this . Insulin ordered at dc however again she stated would not pick up or use . Stated understanding of discussions and voiced that will talk with her pcp after dc. At time of dc was in improved condition .    CONSULTS / RECOMMENDATION: Wound care with dr (Privacy)  Consult Orders (From admission, onward)                IP CONSULT TO WOUND      Provider:  (Privacy), DO          INPATIENT PROCEDURES: None  Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None     BP (!) 149/108  | Pulse 97  | Temp 36.8 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 113.6 kg  | SpO2 93%  | BMI 39.22 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed. She is obese. She is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus.    Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Chest:     Chest wall: No tenderness.  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 tenderness or deformity.     Cervical back: Normal range of motion and neck supple.     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Judgment: Judgment normal.      A Face to Face Attestation is required for the provision of certified home health services.    Once this attestation form is completed, please copy and paste the attestation below into your visit note.     Face to Face Encounter   I certify that this patient is under my care and that I, or a nurse practitioner or physician's assistant working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient on 11/12/2021 (identify the date that the patient was seen for the reason of home care services.  This date can be 90 days prior to or 30 days after the order for home care).   The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care Surgical Aftercare of wound care.   I certify that, based on my findings, the following services are medically necessary home health services: Nursing:  Wound care and assessment.   See History and Physical that support the need for the above services.   Further, I certify that my clinical findings support that this patient is homebound and home is the best place to receive care (i.e. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons) because: Criteria 1 (one required):  Patient has a condition such that leaving their home is medically contraindicated because of immunosuppression & risk of infection. Criteria 2 (both required):  Exists a normal inability to leave the home due to unable to perform stairs and limited ambulation.  Leaving the home requires considerable and taxing effort due to weakness.