Age: 30.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Sepsis, Sputum discoloured, Tachycardia, Ultrasound Doppler normal
Clinical narrative: DISCHARGE DIAGNOSES:         Acute respiratory failure due to COVID-19 pneumonia and asthma exacerbation Sepsis in the setting of suspected covid pneumonia with tachycardia and leukocytosis.  --Patient is Covid vaccinated and got first dose J & J--- second dose in December at the hospital ----Patient had acute onset SOB/wheezing x 2 days, wheezing , cough and yellow phlegm and admitted for COVID-19 and pneumonia/asthma exacerbation.  ---D-dimer < 1.   ---CRP----3.3--- 1.5--0.5 ---WBC---20.8----21.1--- 23 --- Procalcitonin normal--- recheck procalcitonin 0.5 ---Blood cultures were not collected .  ---Chest x-ray on 1/29 shows---Questionable retrocardiac infiltrate. ----Ultrasound of bilateral lower extremity on 1/31 showed---- No evidence of deep venous thrombosis in the lower extremities. --- Patient improved with PTA on albuterol inhaler, montelukast, and Spiriva, IV solumedrol, Breo Ellipta --- Improved oxygenation with NC to 6 L-----room air on rest and ambulation on discharge --- Outpatient follow-up with primary care physician 1 week           Elevated leukocytosis---Due to steroids likely ---WBC---20.8---21.1--23 ----- Procalcitonin normal--- recheck procalcitonin 0.5 --- Outpatient follow-up with primary care physician 1 week         Hyperglycemia due to steroids Blood sugars high started on sliding scale of insulin ---  hemoglobin A1c ---6 on 1/30 ------ Outpatient follow-up with primary care physician 1 week         OSA Obesity hypoventilation syndrome ---- Patient has not been using CPAP at night as her home machine broke ---She states that her CPAP and nebulizer machine are broken--Per nursing patient got new nebulizer machine on 5/21 --- she needs to get new CPAP machine as outpatient after orders from PCP --- Outpatient follow-up with primary care physician 1 week         History of cocaine abuse - Urine tox--- positive for cocaine, marijuana ------ Outpatient follow-up with primary care physician 1 week           Morbid obesity  Outpatient follow-up with primary care physician             SECONDARY DIAGNOSIS/PAST MEDICAL HISTORY:    Past Medical History Past Medical History: Diagnosis Date ? Alpha+ thalassemia (HCC) 07/16/2020 ? Asthma   ? Bipolar II disorder (HCC) 10/14/2015 ? Chronic pain     Lower back pain  ? COVID-19 virus detected 01/29/2022 ? Drug-seeking behavior 08/19/2016   Postoperative s/p c/s on 7/28/16. Presented to OB clinic reporting that medication was stolen from her house. Then presented to L&D reporting that medication was stolen from bus.   Received 35 tablets percocet from internal medicine clinic on 8/18/2016, then 10 tabs roxicodone for pain from ED that same day.  Would caution future prescribers as pain from cesarean section does not typically require ? History of cocaine abuse (HCC) 10/19/2015 ? History of polysubstance abuse 02/15/2016   Last cocaine use ~ 6 months ago, last marijuana use ~ 3 months ago.  ? Intracranial injury (HCC) 04/21/2014   Overview:  Hx of physical abuse and multiple fights w/ head injuries  ? Microcytic anemia 05/16/2013   Per (Privacy) 5/2016- baseline Hgb 10-11. Has past HgB electrophoresis showing probable alpha thalassemia, report not found. Iron studies on 05/17/16 which showed Ferritin 77, TIBC 327, reticulocyte 2.4% saturation calculation 24%.  ? Morbid obesity with body mass index of 70 and over in adult (HCC) 10/13/2020 ? Nonalcoholic hepatosteatosis 10/13/2020 ? Obesity hypoventilation syndrome (HCC) 11/05/2019 ? Obstructive sleep apnea 05/16/2013 ? Other chronic pain 10/13/2020   Due to chronic panniculitis and lumbar pain ? Other problems related to housing and economic circumstances 04/01/2016   (Privacy) Recipient. Referrals obtained and approved by (Privacy) High risk OB, Dr. (Privacy) and hospital 1/1/2016 through 11/1/2016 dates and checked "Consult, diagnose and Treat  ? Provider number (Privacy), (Privacy) PA-C is a provider for a Restricted Recipient for: Physician Services , Nurse Practitioner Services.  ? Provider nu ? Panniculitis 07/09/2020 ? Prediabetes 03/29/2019   7/9/2020 = A1c 5.9% ? Seizure disorder (HCC) 12/11/2015 ? Severe persistent asthma 04/21/2014   History of intubation and frequent hospitalizations d/t exacerbation.  Last Assessment & Plan:  A: Four weeks ago, patient left AMA after being admitted for an asthma exacerbation. She is currently out of her asthma medications. Patient has been using DuoNeb treatments at home. Today, she refused a physical examination but was in no respiratory distress.  P: Continue albuterol and Dulera inhaler.  ? Sleep apnea   ? Traumatic brain injury (HCC) 04/21/2014   Overview:  Overview:  Overview:  Hx of physical abuse and multiple fights w/ head injuries Overview:  Overview:  Hx of physical abuse and multiple fights w/ head injuries Hx of physical abuse and multiple fights w/ head injuries 7/31/2017, (Privacy): Impression: No acute intracranial pathology. ? Verbally abusive behavior 07/23/2016   Patient verbally abusive to staff on L&D. Escalates very quickly. Additionally, has been physically abusive to her S/O at an outside hospital. Recommend discussing appropriate behavior and do not recommend providers go into room by themselves.  Hypertension