Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Sepsis, Staphylococcus test negative
Clinical narrative: Date of Admission  01/12/2022   Date of Discharge  01/14/2022   Reason for Hospitalization   COVID-19 Pneumonia, CAP pneumonia, MS exacerbation.  Hospital Course   This is a 60 yo F, with PMH multiple sclerosis, wheelchair-bound, and flaccid paralysis of bilateral lower extremities, who presented with c/o SOB, non-productive cough, fever, and upper extremity weakness since 1/11. She was found to have LLL consolidation on CTPE, and COVID-19 pneumonia. Neurology consulted for possible MS flare; recommended methylprednisolone 1g x 3 days. Oxygen requirement quickly rose to 8L, but improved to 1L the following. Started COVID treatment, abx, and MS flare steroids.   On 1/14/22, patient down to 1L at rest and 2L with activity. Will discharge on oral amoxicillin and azithromycin to complete abx therapy at home. Patient will go home with 2L O2 and will follow-up with PCP within 4-5 days to ensure resolution. Regarding her MS flare, patient states that she feels baseline after receiving methylprednisolone. Completed 3 day course. Will follow-up in neuro clinic.  Sepsis  LLL Pneumonia  COVID-19 Pneumonia  - Sx onset: 1/11, Positive test: 1/12. Vaccinated including booster.  - MRSA nares negative.  - Procalcitonin elevated.  - RPP only positive for COVID-19.  - Elevated inflammatory markers.  - Patient received methylprednisolone 1g/day for MS flare. Used that in place of dexamethasone.  - Remdesivir.  - Bronchodilator protocol, incentive spirometry, chest PT, mucinex BID.  - TTE normal.  - Ceftriaxone and azithromycin.  - Will discharge on oral amoxicillin and azithromycin to complete abx therapy at home.  - Patient will go home with 2L O2 and will follow-up with PCP within 4-5 days to ensure resolution.  Multiple Sclerosis Flare  - Presented as worsening bilateral upper extremity weakness.  - Neurology consulted: recommended methylprednisolone 1g x 3 days.  - Completed 3-day methylprednisone course. - Continued Gilenya 0.5mg qd x 5 days/week per patient's home regimen.  - Patient will follow up with neurology at scheduled visit in April.  Discharge Diagnoses      1. Multiple sclerosis exacerbation       2. Pneumonia     Ordered:   DME - Home Oxygen Discharge     Orders:   amoxicillin, 1,000 mg = 2 Tablet(s), Oral, q8h, # 12 Tablet(s), Refill(s) 0, 01/16/22, Pharmacy: (Privacy), 165.1, cm, 01/13/22 15:45:00, Height (cm), kg, 01/12/22 10:49:00, Weight (kg), 52.753  azithromycin, 500 mg = 1 Tablet(s), Oral, Daily, # 1 Tablet(s), Refill(s) 0, 01/15/22, Pharmacy: (Privacy), 165.1, cm, 01/13/22 15:45:00 Height (cm), kg, 01/12/22 10:49:00 Weight (kg), 52.753  Discharge Patient  Follow Up Appt Primary Care Provider (PCP)  Other Diagnoses   Ongoing  Multiple sclerosis  Postmenopausal  Weakness  Historical  Acute UTI  Fatigue  Operations and Procedures   None.  Consultants  Neurology   Pending Labs  Culture Blood (Preliminary, InProcess, ordered 01/12/2022, 01:50)   Culture Blood (Preliminary, InProcess, ordered 01/12/2022, 01:50)   Discharge Disposition  Home.  Medications  New, Changed, or Refilled Medications  amoxicillin (amoxicillin 500 mg) 1,000 mg, 2 Tablet(s), Oral, q8h, 12 Tablet(s), 0 Refill(s)    azithromycin (azithromycin 500 mg) 500 mg, 1 Tablet(s), Oral, Daily, 1 Tablet(s), 0 Refill(s)      Medications to be Continued  alpha-lipoic acid (Alpha Lipoic Acid 200 mg) 200 mg, 1 capsule(s), Oral, bid    baclofen (baclofen 10 mg) 10 mg, 1 Tablet(s), Oral, At Bedtime    cholecalciferol (Vitamin D3 1000 intl units) 2,000 IU, 2 Tablet(s), Oral, Daily, 0 Refill(s)    denosumab (Prolia 60 mg/mL subcutaneous solu 60 mg, Subcutaneous, Every 6 Months, 0 Refill(s)    fingolimod (Gilenya 0.5 mg) 0.5 mg, 1 capsule(s), Oral, Daily, except Sunday and Wednesday  Instructions:except Sunday and Wednesday  gabapentin (gabapentin 600 mg) 600 mg, 1 Tablet(s), Oral, qid    lovastatin (lovastatin 20 mg) 20 mg, 1 Tablet(s), Oral, Daily    lutein (lutein 6 mg) 6 mg, 1 capsule(s), Oral, q"other"Day, 0 Refill(s)    multivitamin (Vitamin B Complex) 1 Tablet(s), Oral, q"other"Day, 0 Refill(s)    omega-3 polyunsaturated fatty acids (Nature' 500 mg, 1 capsule(s), Oral, Daily    oxybutynin (oxybutynin 5 mg) 5 mg, 1 Tablet(s), Oral, Daily    vitamin E (vitamin E 100 intl units) 100 IntUnits, 1 capsule(s), Oral, Daily, 0 Refill(s)      Discontinued Medications  None  Physical Exam at Discharge  Vitals & Measurements  T: 36.6 °C  TMIN: 36.6 °C  TMAX: 36.9 °C  HR: 90  RR: 16  BP: 150/78  SpO2: 99%      Constitutional: No acute distress. Cardiovascular: Regular rate and rhythm; normal S1 and S2 without murmur or gallop; no LE edema.  Respiratory: Lungs clear bilaterally (improvement); normal effort; 1L nasal cannula (improvement). No cough present today (improvement). Gastrointestinal: abdomen soft, non-distended, without tenderness or guarding; BS active. Musculoskeletal: 4/5 UE elbow flexion bilaterally. Skin: warm, well perfused, dry, intact. Neurologic: alert and oriented X4; CNs grossly intact; No focal deficits. Psychiatric: normal affect; pleasant and cooperative.     Follow Up Appointments     Follow Up Appt Neurology, Clinic Name/Phone: Neurology Clinic, Provider Name: (Privacy) Within 1 Month, No tests   Follow Up Appt Primary Care Provider (PCP), Provider Name: (Privacy), Within 7 Days, No tests, Comments In 4-5 days. Early next week preferred. f/u on oxygen requirement/hospitalization    Appointment Type  When  With  Where  Contact Information  Status   RT1 04/05/2022 11:00 AM (Privacy) MD, Neurology  MG Mammo Screening 10/25/2022 11:00 AM Radiology Mammogram  Clinics RT1 10/25/2022 11:30 AM (Privacy) APRN, Screening Services  Clinic    Nursing/Other Orders   DME - Home Oxygen Discharge. 01/14/22 12:20:00, Once, 01/14/22 12:20:00, 1/14/2021, 87 , 92 , 84 , 90 , 2 , O2 Liter Flow/FlO2 2, Continuous, Portable gas needed?, Length of need 5 days, Nasal Cannula, Pneumonia   Regular Diet. Ordered on 01/12/22 12:14:00, Meal Start Time Lunch 1115 to 1245   Sofcare Static Air Seat Cushion. 01/12/22 18:32:00, when out of bed to chair   Place pillow between knees when on side. 01/12/22 18:32:00   Right Heel Suspension (Heel/s suspend, right). 01/12/22 18:32:00, off of the bed with pillow, As Indicated   Left Heel Suspension (Heel/s suspend, left). 01/12/22 18:32:00, off of the bed with pillow, As Indicated   Aspiration Precautions. 01/12/22 6:10:00  q24h   Code Status. Code Status Description: Full Code     Addendum by (Privacy), MD on January 16, 2022 13:07:12 (Verified)    Attestation by (Privacy), MD on January 16, 2022 13:07 I personally saw and evaluated the patient on the result date found in the header of this document.  I independently performed the critical/key portions of the Evaluation and Management service and discussed the management with the author of this document.  I agree with everything documented above with the following exceptions/additions: none