Age: 73.0
Sex: F
Vaccine: COVID19-2
Symptoms: SARS-CoV-2 test positive, Sepsis, Tremor, Urine analysis normal
Clinical narrative: COVID+ 10/29/22 - Vaccination Status - Pfizer x4 + pfizer bi-valent BRIEF OVERVIEW: Discharge Provider: DO Primary Care Provider at Discharge: MD  Admission Date: 10/29/2022 Discharge Date: 10/31/2022 Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 10/29/2022 Yes ? Generalized weakness 10/29/2022 Yes ? Acute cough 10/29/2022 Yes ? Essential hypertension 10/29/2022 Yes ? Generalized anxiety disorder 03/08/2021 Yes ? Hyperlipidemia 07/24/2015 Yes ? Asthma 06/10/2014 Yes ? Depression 08/07/2012 Yes ? Restless legs syndrome 08/07/2012 Yes ? GERD (gastroesophageal reflux disease)   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Dehydration [E86.0] Weakness [R53.1] COVID-19 virus infection [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE:    Patient is a 73 y.o. female with past medical history of anxiety, asthma, CVA, depression, dyslipidemia, GERD, hx of uterine cancer, hypertension, restless leg, sleep apnea. Patient is planned to have surgery with Dr. 12/23- arthroscopy right knee and partial meniscectomy. PCP visit 10/28/2022 for cough, sore throat, dizziness, headache, and fever. She was given tessalon perles and phenergan DM. Also instructed to use Claritin or zyrtec, mucinex, and Flonase.     She presents to clinic with seven days of cough, fatigue, fever. Husband reports worsening confusion and weakness over the last couple days. Reports she had increased difficulty walking independently and decreased oral intake for the last 24-48 hours. She did take an at home COVID test on 10/28 which was negative. Reports diarrhea for a couple days with 4-5 episodes daily.    In the ER, she was treated for severe sepsis due to fever (102.2) and altered mental status. 2L fluid hydration given and zosyn given. Hemodynamically stable, not hypoxic. Lactic 1.5-> 1.1. COVID 19 positive, influenza negative, blood cultures collected. BMP and CBC unremarkable. UA negative. Chest x-ray revealed left basilar airspace disease consistent with pneumonia.   During hospital course patient received azithromycin and rocephin for 3 days, will be discharged on azithromycin and keflex for 4 days for a total of a 7 day antibiotic course. Received two days of decadron and will be discharged with 3 additional days. Blood cultures remained negative. Physical therapy recommends skilled PT at discharge. Patient reports stopping many medications, however they are listed on her last outpatient visit. I would recommend a PCP visit to do a medication list reconciliation (maxzide, singulair, symbicort, iron, pramipexole, and dicyclomine).      Patient was seen and examined- alert and oriented. She appears well today, no acute distress. Reports cough has improved- discuss to continue to take tessalon and otc mucinex. Reports fatigue has not changed. Denies shortness of breath, chest pain, chills, fevers, body aches. Tremor and restless leg have improved. Patient is discharged in stable condition- all labs and imaging reviewed. No patient concerns at this time. All questions were answered prior to discharge.      Generalized weakness Patient does have surgery for arthroscopy and partial meniscectomy of right knee in December  -Weakness for several days -PT/OT evaluation and treat ordered -PT recommended skilled PT at discharge  Essential hypertension Normotensive in ER -Patient is prescribed Maxzide at home, she reports she has stopped medication due to improved blood pressure -Will monitor blood pressure Acute cough Secondary to COVID pneumonia  -Dry non-productive cough for 7 days -Tessalon ordered -Mucinex with codeine-> Mucinex   -Cough drops  Generalized anxiety disorder Controlled, home regimen buspar  Hyperlipidemia Home regimen crestor-> Formulary lipitor Asthma Home regimen, PRN albuterol -Singulair and Advair patient stopped  GERD (gastroesophageal reflux disease) Home prilosec-> formulary protonix -PRN zofran Restless legs syndrome Patient stopped home dose mirapex Depression Controlled, lexapro