Age: 90.0
Sex: F
Vaccine: COVID19-2
Symptoms: Pleural effusion, Pneumonia, Procalcitonin, Protein total decreased, Pulmonary congestion
Clinical narrative: Date of Admission Admit Date: Mar-26-2023  Date of Discharge Date of discharge Apr-02-2023  Allergies No Known Allergies  Final Diagnoses Sinus bradycardia  Pneumonia  Acute COVID-19  resolved  Acute hypoxemic respiratory failure Resolved Apr-02-2023  Procedure(s) Performed None  Lab Results Apr-02-2023 0515 Serology PROCALC  0.06 Apr-02-2023 0515 Hematology WBC  15.1RBC  4.26HGB  11.8HCT  35.2MCV  82.6MCH  27.7MCHC  33.5RDW  14.5RDWSD  43.8PLT  300MPV  10.2AUTONEU%  72.3AUTOLYM%  11.0AUTOMON%  6.6AUTOEOS%  0.2AUTOBAS%  0.3ANC AUTO  11.0AUTOLYM#  1.7AUTOMON#  1.0AUTOBAS#  0.0AUTOEOS#  0.0SCAN DIF  YNRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  1.45IG%  9.6 Apr-02-2023 0515 Chemistry GLUCOSE  94BUN  29CREAT  0.7MDRD GFR  78NA  140K  3.9CL  108CALCIUM  8.7ALK PHOS  89CO2  29.2AST  20ALT  29AST/ALT  0.7TL PROT  4.9ALBUMIN  2.3TBILI  0.4DBILI  0.1OSMO  285.0ANION GP  6.7BUN/CRE  41.4CRP  1.00MAGNESIU  1.8PROBNP  467 Apr-02-2023 0515 Blood Gas PH VEN  7.390PCO2 VEN  45.3PO2 VEN  38.0BICARB V  27.0BE VEN  2.2CO2 CT V  24.8O2 SAT V  67.2 Apr-01-2023 2030 Chemistry TROPI-HS  9 Apr-01-2023 1545 Chemistry TROPI-HS  8 Apr-01-2023 0430 Serology PROCALC  <0.05 Mar-31-2023 0745 Serology PROCALC  0.18 Mar-30-2023 0330 Serology PROCALC  0.69 Mar-29-2023 0455 Serology PROCALC  1.65 Mar-27-2023 0553 Chemistry MAGNESIU  1.5 Mar-27-2023 0553 Serology PROCALC  0.93 Mar-27-2023 0119 Coagulation D-DIMER  0.41 Mar-27-2023 0014 Chemistry LACTATE  1.00 Mar-27-2023 0003 Microbiology C BLD  No aerobic or anaerobic growth after 5 nights. Mar-26-2023 2329 Microbiology C BLD  Staphylococcus capitis Mar-26-2023 2126 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  NCVDEMPHC  NCVDSYMP  YCVDSYMDT  032423CVDHOSP  UCVDICU  UCVDRESID  NCVDPREG  N Mar-26-2023 2115 Hematology WBC  14.7RBC  4.60HGB  12.9HCT  38.7MCV  84.1MCH  28.0MCHC  33.3RDW  14.3RDWSD  44.0PLT  203MPV  10.4AUTONEU%  83.7AUTOLYM%  7.3AUTOMON%  6.7AUTOEOS%  0.1AUTOBAS%  0.4ANC AUTO  12.3AUTOLYM#  1.1AUTOMON#  1.0AUTOBAS#  0.1AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.0IG#  0.27IG%  1.8 Mar-26-2023 2115 Chemistry GLUCOSE  128BUN  25CREAT  0.9MDRD GFR  59NA  138K  3.7CL  103CALCIUM  9.0ALK PHOS  119CO2  25.8AST  25ALT  20AST/ALT  1.3TL PROT  6.3ALBUMIN  3.0TBILI  0.7DBILI  0.2OSMO  281.7ANION GP  12.9BUN/CRE  27.8LDH  259CRP  7.20FERRITIN  182ALK PHOS  122AST  27ALT  22AST/ALT  1.2TL PROT  6.3ALBUMIN  3.0TBILI  0.7DBILI  0.2 Imaging Results CXR 1V 4/2/23 Comparison: DX/SR - CH-CHEST PORTABLE 1V DR - 04/01/2023 07:51 AM Findings: Low inspiration. Resultant mild vascular crowding centrally with subsegmental atelectasis. No change in the airspace disease right lower lobe and small right pleural effusion. Stable basilar atelectasis left lower lobe. Cardiomegaly. Improvement passive venous congestion. No acute fractures. Right-sided Port-A-Cath tip superior atriocaval junction. Impression: 1. Low inspiration with central vascular crowding and subsegmental atelectasis. 2. No change in the mild pleural-parenchymal disease right lower lobe. Electronically signed on Apr 2, 2023 6:35:08 AM  by: MD ECHO PER CARDIOLOGY REPORT 04/01/2023  Patient Name: Gender: Female  Study Date: 01-Apr-2023 Tech: Location:  Height(Cm): 152 Weight(Kg): 68.00 BSA: 1.69 Quality: Good Procedures: Echocardiogram complete with 2D, M-Mode, and Doppler examination. Indications: COVID/ SOB. 2D/M Mode Doppler Measurement Value Normal Range Measurement Value Normal Range LVIDd (MM) 5.7 cm AV Area Vmax 3.1 cm2 LVIDs (MM) 3.7 cm AV Area VTI 3.2 cm2 IVSd (MM) 1.4 cm AV Peak PG 3.0 mmHg LVPWd (MM) 1.4 cm MV Mean PG 0.5 mmHg LA Dimen MM 4.2 cm MV Area 2.6 cm2 LA Volume Index 33.0 ml/m2 LVOT Peak Vel 0.5 m/sec EF Biplane 61 % E/E` 16.0 Findings Left Ventricle: Moderate left ventricular hypertrophy (measuring 1.4 - 1.7 cm). The left ventricular ejection fraction is measured at 61 %. Impaired relaxation (Grade I diastolic dysfunction). Left Atrium: Mild left atrial enlargement which is consistent with LA index volumes between 35 - 41 cm2. Mitral Valve: Mild mitral regurgitation. Mild mitral annular calcification. Aortic Valve: Aortic cusps appear mildly calcified. Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function. Right Atrium: Normal with RA size <40mm. Atrial Septum: Normal atrial septum. Tricuspid Valve: Normal appearance and function of the tricuspid valve with trace physiologic regurgitation. Normal right ventricular systolic pressure. Pulmonic Valve: Normal pulmonic valve appearance and function with trivial (physiologic) regurgitation. IVC: Normal inferior vena cava appearance and respiratory collapse. Aorta: Aortic root size is normal. Pericardium: Normal pericardium with no significant pericardial effusion. Conclusions Moderate left ventricular hypertrophy (measuring 1.4 - 1.7 cm). The left ventricular ejection fraction is measured at 61 %. Impaired relaxation (Grade I diastolic dysfunction). Mild left atrial enlargement which is consistent with LA index volumes between 35 - 41 cm2. Mild mitral regurgitation. Mild mitral annular calcification. Aortic cusps appear mildly calcified. Technically difficult study. Electronically Signed By: D.O. 01-Apr-2023 09:10:41 -0500 Patient Name:  Study Date: 01-Apr-2023  CHEST X RAY PER RADIOLOGY REPORT 04/01/2023 Patient Name:   Date of Exam: 4/01/2023 Gender: F Ordering Physician: RESIDENT Exam Description: CH-CHEST PORTABLE 1V DR RADIOLOGY INTERPRETATION PATIENT NAME:  DATE OF EXAM Apr 1, 2023 7:51:45 AM  PROCEDURES CR - Chest 1 view HISTORY hypoxia, mucous plugging, covid + IV CONTRAST (if appl) 1 view chest x-ray. Comparison: DX - CH-CHEST PORTABLE 1V DR - 03/29/2023 11:42 PM DX - CH-CHEST 1V DR - 03/28/2023 06:19 AM  DX - CH-CHEST 1V DR - 03/26/2023 09:44 PM  Findings: Stable low lung volumes. Worsening airspace disease right lower lobe. Small right pleural effusion. Stable cardiomegaly. No passive venous congestion. Ectatic thoracic aorta with mild tracheal deviation to the right unchanged. No acute fracture. Right-sided Port-A-Cath tip atriocaval junction. Impression: 1. Worsening pleural-parenchymal disease right lower lobe. Poor inspiratory effort. Cardiomegaly without heart failure. The above study was officially reviewed, dictated, and signed by a radiologist from Radiology (teleradiology company). The report has then been proxy signed by an associate   The below radiology associate assignment and electronic signature (proxy signature) only represents completion of the electronic process. The Page 1 of 2 signature does not represent a review or interpretation of any radiology image(s) that were dictated in the report. This exam was interpreted on workstation DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 4/1/2023 9:23 AM   CTA OF PULMONARY ARTERY PER RADIOLOGY REPORT 03/31/2023 Date of Exam: 3/31/2023 Gender: F Ordering Physician:  Exam Description: CTA PULMONARY ART. EXAM: CTA PULMONARY ART. INDICATION: Hypoxia TECHNIQUE: 100 mL IV Isovue. Pulmonary embolism protocol CTA chest. Up-to-date CT equipment and radiation dose reduction techniques were employed. 3D postprocessing. MIP imaging. COMPARISON: None FINDINGS: Limitations: Mild respiratory motion artifact. Body wall: Right-sided chest port in good position. Visualized thyroid: Negative. Bulky or pathologic lymphadenopathy: None. Heart size: Mildly enlarged. Aorta: No acute abnormalities. Vascular calcifications with coronary involvement. Pulmonary arteries: No large or central pulmonary embolus. Evaluation of the small peripheral pulmonary vessels limited by motion artifact. Pleural/pericardial effusions: Small right pleural effusion with associated atelectasis. Visualized upper abdomen: Small hiatal hernia. Adenomatous hyperplasia of the adrenal glands. Left kidney cyst. Trachea and large airways: Soft tissue material in the right mainstem bronchus and right lung airways consistent with mucous plugging or neoplasm. Lung parenchyma: No suspicious nodule, mass, or focal consolidative process. Old granulomatous disease. Bones: No pathologic bone lesion or acute osseous findings. Advanced Page 1 of 2 degenerative disease bilateral shoulders. Miscellaneous/Incidental findings: Elevated right hemidiaphragm. IMPRESSION: 1. Soft tissue material in the right mainstem bronchus and right lung lobe airways consistent with mucous plug or neoplasm. Consider bronchoscopy. 2. Small right pleural effusion with associated atelectasis. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 3/31/2023 4:37 PM   CXR 1V 3/31/23 HISTORY: Pneumonia. COVID-19 positive. TECHNIQUE: AP upright portable chest obtained at 0905 hours COMPARISON: 3/29/2023 and 3/28/2023 FINDINGS: Low lung volumes. Mild central pulmonary vascular congestion. Elevated left hemidiaphragm, unchanged. Worsening right pleural effusion with associated atelectasis and/or consolidation. Stable cardiomegaly which is accentuated by portable technique. Severe bilateral glenohumeral joint degenerative changes. Loose body inferiorly left glenohumeral joint. Right subclavian Infuse-a-Port without complication or change. IMPRESSION: 1. Worsening right pleural pleural effusion with associated atelectasis and/or consolidation. 2. Stable cardiomegaly. This exam was interpreted on workstation  DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 3/31/2023 9:40 AM   CXR 1V 3/29/23 Comparison: DX - CH-CHEST 1V DR - 03/28/2023 06:19 AM  DX - CH-CHEST 1V DR - 03/26/2023 09:44 PM  Findings: A right chest port with distal tip overlying the expected location of the cavoatrial junction. The heart size is enlarged but stable from the prior examination. Unchanged bilateral pleural effusions greater on the right than left with passive atelectasis or parenchymal consolidation within the right lung base. Increasing interstitial opacities throughout the entirety of the right lung with new confluent opacity involving the right hilar and suprahilar region. The hilar based consolidation may represent developing infiltrate. No acute fracture. Advanced degenerative changes of the bilateral shoulders and thoracic spine. IMPRESSION: 1. New confluent opacity at the right hilar/suprahilar region may represent developing hilar based infiltrate. Increasing interstitial haziness throughout the entirety of the right lung. Stable bilateral pleural effusions. Electronically signed on Mar 30, 2023 3:42:58 AM by: DO  CXR 1V 3/28/23 Comparison: DX - CH-CHEST 1V DR - 03/26/2023 09:44 PM Findings: Right-sided MediPort present with the tip of the catheter in the SVC. Heart is enlarged. Probable small pleural effusions with hazy bibasilar opacities similar to prior. No pneumothorax. Severe degenerative changes of the shoulders. IMPRESSION: 1. Cardiomegaly with small pleural effusions and hazy bibasilar airspace opacities similar to prior. Electronically signed on Mar 28, 2023 6:33:22 AM by: MD    CXR 1V 3/26/23 Findings: Low inspiratory lung volumes. Ill-defined opacities in right mid to lower lung and left lung base. There may be a right pleural effusion not well seen. Right internal jugular chest port catheter is near the cavoatrial junction. Cardiomegaly. Severe bilateral shoulder degenerative changes. Large left inferior glenohumeral loose body. IMPRESSION: Bibasilar lung opacities with possible right effusion. Recommend follow-up. Electronically signed on Mar 26, 2023 10:16:23 PM by: MD  Functional Status* No Functional Impairments  Mental Status* Normal Cognition  Social History tobacco use Never Smoked, Smoking Cessation Not Applicable  marital status Married  Health Concerns Sinus bradycardia  Acute hypoxemic respiratory failure  Pneumonia  Acute COVID-19  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Apr-02-2023 1003 O2Sat 94 Apr-02-2023 0912 O2Sat 99 Apr-02-2023 0730 T 98.2 HR     43 RR 20 BP   139 / 60 Apr-02-2023 0400 T 97.5 HR     49 RR 20 BP   132 / 59 PHYSICAL EXAM CONSTITUTIONAL: Patient appears younger than stated age. Comfortable and in no acute distress. CARDIOVASCULAR: Heart has regular rate and rhythm, pulses are 2/2 in the upper extremities, no edema noted. RESPIRATORY: Lungs clear to auscultation throughout and respiratory effort is non-labored. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. Bowel sounds normoactive. NEUROLOGICAL: Patient is alert and oriented x 4. Sensation is grossly intact. PSYCHIATRIC: Patient's mood is witty, affect is appropriate. RASS of 0.  Consultations DO GENERAL SURGERY  DO  CARDIOLOGY  Hospital Course Patient is a 91-year-old female presents to the ED from home with a chief complaint of general weakness a 4 day worsening duration with a past medical history of hypertension, hyperlipidemia, endometrial cancer in remission currently receiving Q three-week chemotherapy who was admitted under the care of inpatient medicine for sepsis and acute hypoxic respiratory failure secondary to COVID pneumonia with right lower lobe pneumonia. She required supplemental oxygen upon admission. Checks x-ray right perihilar air bronchogram likely right lower pneumonia. Patient was treated with remdesivir for 5 days and dexamethasone for her COVID-19 and azithromycin and 1 dose of ceftriaxone for possible bacterial pneumonia. Incentive spirometer and flutter valve were also utilized during her stay. On 3/27 and 3/28 patient's oxygen requirements went up to 5 L NC with going back to 3 L in daytime. On the evening of 3/29 patient was desaturating to low 80s even on 5 L NC, CXR was ordered which showed worsening pneumonia, patient placed on Zosyn on 3/30/23 and put up to nonrebreather mask, which she required the following night as well. On 3/31/2023 CTA of pulmonary artery was ordered and general surgery was consulted for possible bronchoscopy due to radiology report. Patient and family declined bronchoscopy. Lasix was given on 03/30 and 03/31. Patient/family refused the bronchoscopy. During her hospital stay, patient was bradycardic in the upper 40's. Dr. of cardiology was consulted who assessed the patient. Given she was asymptomatic, we decided to discharge patient on Holter monitor for 2 weeks to monitor her HR.  On the date of discharge, patient was able to maintain her oxygenation on room air both at rest and while working with PT. Simple pulmonary stress test was negative. Patient had bowel movement and eats what she can but doesn't like the food because it's always cold. She anticipates eating more once she gets home. She denies any shortness of breath or cardiac symptoms. She was deemed stable for discharge from surgical, cardiac and medical standpoint on oral antibiotics and steroid to complete COVID-19 treatment.  Condition at Discharge Stable  Discharge Medications Atorvastatin Calcium Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY Calcium 1200 Oral Tablet Chewable 1200-1000 MG-UNIT 1 TAB ORALLY ONCE A DAY Cefdinir Oral Capsule 300 MG 300 MG ORALLY TWICE DAILY (ePrescribed by RESIDENT on Apr-02-2023 1439) Dexamethasone Oral Tablet 6 MG 6 MG ORALLY ONCE A DAY (ePrescribed by RESIDENT on Apr-02-2023 1439) Eliquis Oral Tablet 2.5 MG 1 TAB ORALLY TWICE DAILY Keytruda Intravenous Solution 100 MG/4ML 1 SYR INJECTION EVERY 3 WEEKS Lisinopril Oral Tablet 20 MG 20 MG ORALLY ONCE A DAY Pregabalin Oral Capsule 25 MG 25 MG ORALLY ONCE A DAY Discharge Disposition Discharge to home with home health  Plan ASSESSMENTS: -sepsis, leukocytosis 14.7 and afebrile temperature 102°, right lower lobe pneumonia, improving -acute hypoxic respiratory failure, requiring 3 L HFNC on admission, improving down to 3 L HFNC which is down from yesterday's 10 L HFNC, resolved -COVID-19 pneumonia, acute, on dexamethasone, completed remdesivir -Hypomagnesemia, acute 1.6 03/31/2023, persistent, replaced  -hypertension, chronic, unknown control -hyperlipidemia, chronic, unknown control -endometrial cancer, history of, in remission, currently receiving chemotherapy q. 3 weeks injection  PLAN: The patient's condition is stable at this time and will be discharged today to home with home health (skilled nursing and PT). We will discharge the patient on their home medications as reconciled above. We will send the patient home with dexamethasone 6 mg q.d. for 3 days for treatment of COVID-19.  Patient was placed on azithromycin started 3/26/23 for the treatment of pneumonia as well as Zosyn 3.375 q.6 which was started on 3/30/23. We are discharging the patient on cefdinir 300 mg b.i.d. for 2 days to complete a total treatment course of 5 days for pneumonia. She was encouraged to use incentive spirometer. Advised if worsening condition, oxygen saturation < 92%, or unable to tolerate oral intake, to go to ED. Patient can use OTC Mucinex to help with cough and expectoration PRN. Advised against double dosing on Tylenol while taking Mucinex. Patient and family at bedside expressed understanding to this plan and agreed. We recommend the patient follow up with PCP within 1 week for hospital follow-up.  Patient should also follow up with Dr. within 2-4 weeks outpatient for her bradycardia. She will be discharged on a Holter monitor which will also need to be reviewed by Cardiology. We thank Dr. and his team for the assistance in caring for this patient.  The patient was evaluated by Dr. and the plan of care was discussed with this resident.   DO Family Medicine  Primary Care Provider MD  Electronically signed on Apr-02-2023 1750 I have seen and physically examined the patient on [4/2/23] and agree with the documentation of [Dr]. I have also discussed my findings and plan of care with [Dr]. Any changes and additional information are listed below. Electronically signed by MD on Apr-02-2023 1817