Age: 71.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: COVID-19, COVID-19 pneumonia, Chest X-ray normal, Condition aggravated, Cough
Clinical narrative: Hospitalized (admitted 8.28);  COVID-19 exposure and symptoms 8.25.21;  COVID-19 positive 8.28.21 (fully vaccinated) Currently still admitted to the hospital.  CHIEF COMPLAINT COVID   ASSESSMENT AND PLAN Covid pneumonia  - patient presenting with cough, SOB, fevers, weakness for the last 3 days. Husband is also Covid positive.  Fully vaccinated with Pfizer. - satting well on room air but did have episode of desaturation to 88%, recovered quickly - Covid positive 8/28 - CXR negative for acute process - started on decadron, continue - does not currently qualify for Remdesivir  - prn cough meds - monitor on pulse ox   Mechanical falls - notes she has had 3 mechanical falls in the last 3 days. Last fall was yesterday and she states they were from "getting tripped up" not really from weakness. Had to call sister to help with getting her off the floor. Denies hitting head and not on AC.  - PT/OT eval   Essential HTN - continue home Norvasc   Crohn's disease - holing home Imuran and Humera with acute infection   Epilepsy - continue home Lamictal   Anxiety - home ativan PRN   Chronic anemia - hgb 10.3 which is around recent baseline   Hx SDH with chronic R sided weakness HDL - continue home ASA and stain   Hx DVT/PE - not currently on AC   Diet:  general VTE Prophylaxis:  Lovenox Code status: Full code per discussion with patient and sister at bedside   Above assessment and plan discussed with Dr. whose insight is reflected above.   HISTORY OF PRESENT ILLNESS Patient is a 71 y.o. female with past medical history significant for Crohn disease on chronic anemia depression, anxiety, subdural hematoma with chronic right-sided weakness, epilepsy, hypertension, history of DVT/PE who presented emergency department complaints of cough, shortness of breath and weakness.  Patient states that her husband was found to be COVID positive recently.  She was seen at urgent care a few days ago and was negative but states that she has had worsening symptoms.  Cough has been productive and she has been having intermittent shortness of breath.  Has been having fevers at home with most recent being this morning.  She also notes a decreased appetite and minor sore throat.  Patient notes that she is fully vaccinated with Pfizer.  Per patient and sister at bedside, they noted patient had 3 mechanical falls in the last 3 days.  Last fall was yesterday.  Patient states that these falls were secondary to ?getting tripped up? and not necessarily from weakness.  She does have chronic right-sided from her prior stroke.  Patient states that she had to call her sister for assistance getting off the floor has her husband is currently weak with COVID and was unable to help.  Patient denies having had any of her falls.  Patient is also not currently on any anticoagulation.  Denies any chills, lightheadedness/dizziness, loss of taste or smell, chest pain, abdominal pain, nausea/vomiting, diarrhea urinary symptoms.   Upon arrival to emergency department, patient was tachypneic.  Baseline blood work was obtained showing minor hyponatremia of 132, slight bump in her creatinine to 0.99, minor leukocytosis of 12.8 with lymphopenia, stable chronic anemia.  COVID PCR was positive.  CXR was obtained was negative for acute process.  Patient was stable on room air for most of her stay in the ER.  She did have 1 episode of desaturation to 88% but did recover quickly.  Patient was then started on Decadron.  She was then admitted to General Medicine under observation for further evaluation and management.