Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Pyrexia, QRS axis abnormal, Respiratory tract congestion, Retching, SARS-CoV-2 test positive
Clinical narrative: Went to ED on 12/2/2021 - held there awaiting bed/admission to hospital.  D/c'd 12/3/2021.  COVID + 12/2/2021.  Fully vaccinated with 2 doses moderna. ED NOTE: DIAGNOSIS at time of disposition:   1. COVID-19  2. Sepsis without acute organ dysfunction, due to unspecified organism (HCC)  3. Acute respiratory failure with hypoxia (HCC)      ED Disposition    ED Disposition   Hospitalized           Objective     MEDICAL DECISION MAKING:   Patient was signed out to me at shift change by Dr.  In short, patient is a 73-year-old female presented to the emergency department hypoxic with COVID-19.  She was admitted to the hospital the boarding in the emergency room.  Patient was requiring 4 L of oxygen initially.  However, this was able to be weaned down to 2 L. This is the patient's baseline.   Hospitalist evaluated the patient in the morning and felt the patient was stable for discharge.  Refer to their discharge summary for more details on the patient's hospital course.  The patient was ultimately discharged by the hospitalist service.  ED Disposition    ED Disposition   Hospitalized     Condition at disposition: stable   FOLLOW UP: 1. Standard after care instructions provided. 2.  Follow Up Instructions: 3. The following items were considered and discussed with the patient at today's visit:  o Today's diagnosis o Any medication/s prescribed o Diagnostic tests ordered and reviewed o Available previous medical records obtained and reviewed 4.   BLOOD PRESSURE SCREENING: Based on last blood pressure taken in the ED of (!) 157/44, active Diagnosis of HTN, patient excluded from screening.      MEDICAL DECISION MAKING/ ASSESSMENT & PLAN: MDM Patient is brought to the treatment area under severe respiratory precautions.  History is obtained from the patient and her prior records.  The patient is examined as noted.  She is placed on supplemental oxygen 4 L which did stabilizer respiratory status to some degree she remained tachypneic but her pulse ox held in the mid to low 90s thereafter.  Diagnostics noted below are initiated.  Patient's lactic acid level is normal and her procalcitonin was 0.11.  Chest x-ray suggestive of left-sided pneumonia COVID or otherwise.  Patient does meet sepsis criteria and blood cultures are pending the patient is given antibiotics.  However as the patient has COVID fluid resuscitation is not aggressive.  Patient's blood pressure remained stable.  Patient is given albuterol meter dose inhaler with perhaps slight improvement in her respiratory status, she is also given cough medication and Decadron.  I have discussed results the patient's tests with the patient.  I have personally consulted with the hospitalist was agreed to admit the patient hospital for further evaluation treatment.  However there are no hospital beds available so her care will be continued here in the emergency department for the time being DISCHARGE NOTE: Discharge Provider:  DO Primary Care Provider at Discharge:MD  Admission Date: 12/2/2021 Discharge Date: 12/3/2021   Active Hospital Problems   Diagnosis Date Noted POA ? Hypertension 12/02/2021 Yes ? Chronic obstructive pulmonary disease (HCC) 12/02/2021 Yes ? Paroxysmal atrial fibrillation (HCC) 12/02/2021 Yes ? Acquired hypothyroidism 12/02/2021 Yes ? Other hyperlipidemia 12/02/2021 Yes ? Acute hypoxemic respiratory failure due to COVID-19 (HCC) 12/02/2021 Yes ? Sepsis (HCC) 12/02/2021 Yes ? Alzheimer's dementia without behavioral disturbance (HCC) 12/02/2021 Yes ? Coronary artery disease involving native coronary artery of native heart without angina pectoris 12/02/2021 Yes ? Class 2 obesity in adult 12/02/2021 Yes   Resolved Hospital Problems No resolved problems to display.   Pre-Existing Active Problems   Diagnosis Date Noted POA ? Diabetes mellitus (HCC) 12/02/2021 Unknown ? Persistent atrial fibrillation (HCC) 12/02/2021 Unknown  Active Issues Requiring Follow-up Sepsis (HCC) Assessment & Plan Resolved   Present on admission and evident by fever, tachycardia, tachypnea and leukocytosis.  Source is likely COVID pneumonia    Paroxysmal atrial fibrillation (HCC) Assessment & Plan Continue Cardizem and Eliquis Patient currently in sinus rhythm   Chronic obstructive pulmonary disease (HCC) Assessment & Plan Continue home meds   * Acute hypoxemic respiratory failure due to COVID-19 (HCC) Assessment & Plan Continue home supplemental oxygen Patient saturating 95% while sitting at bedside combing hair/brushing teeth Continue oral decadron on discharge       DISCHARGE DISPOSITION: Home without services   No future appointments. Appointments Needing to be Scheduled Instructions for after discharge    Call the Doctor for Redness, Tenderness, or Signs of Infection at IV or Procedure Site(s)   Complete by: As directed     Read New Medication Instructions   Complete by: As directed     Resume Normal Activity as Tolerated   Complete by: As directed     Resume Normal Diet   Complete by: As directed       DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01]   HOSPITAL COURSE: PT is a 73 y.o. female who presents to the ER on 12/2 with shortness of breath.  Patient recently moved to this area with her husband from the medical center.  She does not have a primary care physician.  Patient reports feeling ill for about the last 3 weeks.  She has had chills she has been nauseous and had dry heaves.  About week ago she developed a cough that has been nonproductive but unrelenting.  She sought attention in urgent care center on November 26th.  She was diagnosed with probable COVID.  She was not hypoxic and her chest x-ray showed no evidence of viral pneumonitis.  Patient was able to be discharged to home.  On Monday she took a home COVID test and was positive.  Her daughter, who she lives with, also tested positive.    Her daughter convinced her to be evaluated emergency department.  On presentation the patient was febrile with temperature of 102.6°.  She was tachycardic with heart rate 112 and tachypneic with respiratory rate of 31. Oxygen saturations on room air were 85%.  Further evaluation showed leukocytosis of 13.1.  COVID testing was positive.  Chest x-ray showed suggestion for subtle airspace disease.     Patient was admitted to the hospital and treated with IV decadron and IV remdesivir.   She maintained O2 sat of 91% to 95% while on 2 LPM.  Patient to be discharged home, in stable condition with a prescription of decadron to take daily.  Patient is to continue her home oxygen at 2 LPM.     BP 147/66  | Pulse 69  | Temp 98.1 °F (36.7 °C) (Oral)  | Resp 22  | Ht 1.651 m (5' 5")  | Wt 102.7 kg (226 lb 6.6 oz)  | SpO2 92%  | BMI 37.68 kg/m²  FIO2 (%): 2 % Physical Exam Vitals and nursing note reviewed.  Constitutional:      Appearance: She is well-developed and normal weight.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.  Musculoskeletal:        General: No swelling. Normal range of motion.     Cervical back: Normal range of motion.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.        PERTINENT LABS AND STUDIES: Radiology results reviewed from the following date(s): since admission Lab results reviewed from the following date(s): since admission