Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Acquired diaphragmatic eventration, Acute respiratory failure, Anion gap, Anticoagulant therapy, Anxiety
Clinical narrative: Hospitalized (1.24.22 - 1.27.22); COVID-19 positive (1.24.22); Fully vaccinated - moderna x2 d/c summary: Discharge Summary (Resident)  Cosigned by: privacy at 1/27/2022  3:21 PM Attestation signed by privacy at 1/27/2022  3:21 PM Hospitalist Note:   Patient evaluated and examined on 1/27/2022.   I have seen and examined the patient and read and verified the details of the resident/app?s note.  I agree with the assessment and plan, which I discussed and supervised. Patient is a 71 y.o. old male admitted for acute hypoxic respiratory failure secondary to COVID-19 pneumonia with superimposed bacterial pneumonia.    MDM: Patient will finish steroids and antibiotics at home for his COVID-19, discharged home without home O2.    35 minutes were spent coordinating patient's discharge.  More than 50% of this time was counseling the patient on the need for close follow-up with patient's primary care physician, review of medication risks and benefits as indicated, signs of worsening illness, and reasons to return to the primary care physician or Emergency Department for reevaluation.    MD     DISCHARGE SUMMARY    BRIEF OVERVIEW: Discharge Provider:  MD Primary Care Provider at Discharge: MD Admission Date: 1/24/2022 Discharge Date: 01/27/2022    DISCHARGE DIAGNOSES 1. Acute exacerbation chronic obstructive pulmonary disease 2. COVID-19 pneumonia 3. Superimposed community-acquired pneumonia 4. Tobacco use   PROCEDURES Chest x-ray   Surgery and Procedures    None   Non-surgical Procedures (From admission, onward)   None       CONSULTS IP CONSULT TO CARE MANAGEMENT   DETAILS OF HOSPITAL STAY: HOSPITAL COURSE: Patient is a 71 y.o. male who presented with fever, diarrhea, nausea, vomiting, congestion, productive cough, shortness of breath.  His symptoms have been going on for 8 days at presentation and he was using a friend's oxygen for several days prior to presenting to the emergency department.  He was maintained on supplemental oxygen 2 L nasal cannula in the emergency department but did saturate quickly on room air.  Chest x-ray identified findings of likely inflammatory infiltrate at left lung base.  He was started on steroids and antibiotics for COVID pneumonia, acute exacerbation of chronic obstructive pulmonary disease, and suspected superimposed bacterial infection.   Patient was independent in his room and did not require escalation past nasal cannula during his hospitalization.  He did have an episode of anxiety with being decreased to room air and was placed back on 0.5 L nasal cannula for comfort at rest.  Before discharge she was evaluated by respiratory therapy for home oxygen and did not need any oxygen at rest or with activity.  He was discharged home with prescriptions for steroids to complete a 10 day course as well as several days of Ceftin to complete his course of antibiotics for community-acquired pneumonia.  He was also provided with prescriptions for Tessalon Perles as he found these helpful to limit his coughing. Instructions for follow-up were provided and he was discharged in stable and improved condition.   BP 144/91  | Pulse 103  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.803 m  | SpO2 95%  | BMI 22.87 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not ill-appearing, toxic-appearing or diaphoretic.     Interventions: Nasal cannula in place.     Comments: Nasal cannula in place  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Examination of the right-lower field reveals rales. Decreased breath sounds and rales present.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.   H&P:   History and Physical  CHIEF COMPLAINT: Shortness of breath, heart racing    Subjective    HISTORY OF PRESENT ILLNESS: Patient admits to 8 days of COVID symptoms including fever, diarrhea, nausea vomiting, sinus congestion, rhinorrhea, cough, productive of sputum.  He is vaccinated against gets SARs CoV 2, he has yet to receive a booster.  He had ill contacts with COVID in household.  He reports on Saturday he began getting short of breath, check his pulse ox and it was 87%. His friend brought over oxygen and put him on 4L "and I was able to get my oxygen up to 94%". He reports that he was using he over the counter remedies including Vicks with some relief of congestion. Ultimately he came to the hospital because he was getting heart palpitations which made him feel ?hot in the face and I could not breathe?.  He reports that he continued to smoke until week ago, declines nicotine patch.   During emergency department course, he was able to maintain saturations on 2 L oxygen.  Emergency department provider noted that he did desaturate quickly into the high 80s when he was on room air.  Laboratory studies revealed a WBC of 10.96, otherwise relatively unremarkable.  CXR with findings opacifications of the left lung base which could be inflammatory infiltrate but could also be secondary to patient's marked pectus excavatum.  He was given IV Decadron in the emergency department.  He will be admitted to the general medicine service for acute hypoxic respiratory failure secondary to COVID-19 pneumonia Review of Systems Constitutional:  Positive for appetite change and fever. Negative for chills.  HENT: Negative for rhinorrhea, sore throat and trouble swallowing.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough, shortness of breath and sputum production. Negative for wheezing.   Cardiovascular:  Positive for palpitations and leg swelling. Negative for chest pain.  Gastrointestinal:  Positive for nausea, vomiting and diarrhea. Negative for abdominal pain, constipation and trouble swallowing.  Genitourinary:  Negative for difficulty urinating and dysuria.  Musculoskeletal:  Positive for edema. Negative for joint swelling.  Neurological:  Positive for headaches and weakness (generalized). Negative for loss of consciousness.  Endo/Heme/Allergy:  Negative for easy bleeding or bruising.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for rash.  OBJECTIVE: BP 140/81  | Pulse 103  | Temp 98.4 °F (36.9 °C) (Oral)  | Resp 30  | SpO2 (!) 89%   Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is ill-appearing.     Interventions: Nasal cannula in place.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Examination of the right-lower field reveals rales. Decreased breath sounds and rales present.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.  ASSESSMENT/PLAN:   Acute Exacerbation of COPD 2/2 COVID  - CXR read as abnormal opacification at the LL base which could represent infiltrate  - no oxygen at baseline  - wean oxygen as tolerated  - albuterol mdi q 4h  - patient was on samples of Trelegy and ran out  - start Symbicort and Spiriva  - IV SoluMedrol 40 mg q6h - received IV Zithromax in ED, continue po Zithromax x 4 days  - incentive spirometry and acapella  - sputum sample    COVID 19 Viral Pneumonia  - symptoms started 1/17 sx day #8  - vaccinated against SARS-CoV-2, overdue for booster  - imaging with findings concerning for covid pneumonia - oxygen requirement 2L  - given 6mg IV dexamethasone in ED, continue IV SoluMedrol  - outside the window for MAB and Remdesivir  - daily labs CBC w/ differential, CMP, CRP, Ddimer  - continuous pulse oximetry  - encourage IS and pronation  - antitussives prn  - VTE prophylaxis with Lovenox  - mild leukocytosis, copious yellow sputum and elevated procal; will add Zithromax and Rocephin for cover for superimposed bacterial infection    Tobacco Abuse - patient has not smoked in one week due to illness  - nicotine patch prn