Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: SARS-CoV-2 test positive, Sinus congestion, Sputum discoloured, Troponin
Clinical narrative: Date of Admission 02/09/2022; Date of Discharge 02/10/2022; Reason for Hospitalization;  COVID X7 DAYS; REPORTED SPO2 BELOW 92% AT HOME;Hospital Course; COVID; A 47 year old female with PMHx cholecystectomy, gastric sleeve who presents to the ED with worsening shortness of breath, sinus congestion, and cough for several days. Patient tested positive for COVID ED on 2/4.  Endorses sore throat and worsening cough productive of green, yellow, and dark red sputum. Endorses chest pain (3/10 in severity) in center of chest that is worsened by coughing. Reports that she has not eaten much since Thursday or Friday.  Endorses diarrhea x3 days and foul smell. Endorses loss of taste and smell for approximately 5 days. and poor oral intake of food due to nausea.  On 2L O2 in the ED, no oxygen requirements at home. EKG and troponins in ED rule down ACS. CXR ruled down PNA, pneumothorax, or CHF. Given 1L NS for hydration in setting of illness and lightheadedness. S/P dose of Dexamethasone in the ED. Patient was admitted and given Dexamethasone 6mg daily starting 2/9.  Patient had home oxygen evaluation and saturation remained above 92% with exertion. However, patient requested home oxygen at discharge and paid for it out of pocket. Discharge Diagnoses. COVID; Unspecified Mood Disorder;Hashimoto's Thyroiditis; Ordered: DME - Home Oxygen Discharge; Orders: Dexamethasone, 6 mg = 1.5 Tablet(s), Oral, Daily, # 8 Tablet(s), Refill(s) 0, 02/18/22, Pharmacy: MIZZOU PHARMACY UNIVERSITY HOSP, Please deliver to bedside, 156, cm, 02/09/22 15:50:00 CST, Height (cm), kg, 02/09/22 15:50:00 CST, Weight (kg), 63; Discharge Patient; Follow Up Appt External Clinic or Provider; Transition of Care - External; Operations and Procedures; None; Discharge Disposition; Home; Medications New, Changed, or Refilled Medications Dexamethasone (dexamethasone 4 6 mg, 1.5 Tablet(s), Oral, Daily, 8 Tablet(s), 0 Refill(s),Medications to be Continued: Fluoxetine (Fluoxetine 20 mg) 20 mg, 1 Tablet(s), Oral, qAM; Cyclobenzaprine (cyclobenzapri 10 mg, 1 Tablet(s), Oral, tid, PRN: chest tightness, 30 Tablet(s), 0 Refill(s)    Gabapentin (gabapentin 100 mg) 200 mg, 2 capsule(s), Oral, At Bedtime, 0 Refill(s);  Levothyroxine (levothyroxine 5 50 mcg, 1 Tablet(s), Oral, Daily; Multivitamin, prenatal (MULTIV 1 Tablet(s), Oral, daily; Trazodone (trazodone 100 mg) 100 mg, 1 Tablet(s), Oral, At Bedtime, 0 Refill(s); Discontinued Medications; No Home Medications; Physical Exam at Discharge  Vitals & Measurements; T: 36.9 °C  TMIN: 36.4 °C  TMAX: 36.9 °C  HR: 61  RR: 18  BP: 113/76  SpO2: 95% ;Constitutional: No acute distress, appears uncomfortable. On 2.5 L O2; Eyes: Appears to have normal vision, EOMI;HENT: NCAT, moist oral mucosa; Neck: Atraumatic, normal skin, no masses palpated. Respiratory: breathing comfortably, normal respiratory rate, CTA,  CV: normal peripheral perfusion, acyanotic, RRR, no MRG, the sternum and chest wall is mildly tender palpation. Abdomen: Nondistended, nontender, soft. MSK: Normal range of motion, normal strength, normal gait. Neuro: No focal deficits, alert and oriented. Psych: Appropriate mood and affect. Skin: Warm, dry, intact. Time Spent 1 hour.Follow Up Appointments. Follow Up Appt External Clinic or Provider, Clinic Name: Compass Health Network, Provider Name: Leslye Schulte FNP, Within 7 Days, No tests. Nursing/Other Orders. DME - Home Oxygen Discharge. 02/10/22 14:32:00 CST, Once, 02/10/22 14:32:00 CST, 2/10/2022, 90 , 92 , 87 , 93 , 2 , O2 Liter Flow/FlO2 2, With exercise, Portable gas needed?, Titrate for conserver, Length of need 99, Nasal Cannula, COVID. Regular Diet. Ordered on 02/09/22 15:53:00 CST, Meal Start Time Breakfast 0700 to 0900   Activity As Tolerated. 02/09/22 15:53:00 CST, Continuous Order. Code Status. Code Status Description: Full Code. [1] Admission; Addendum. 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 more than 35 Min's spent in dc planning , med rec, care coordination and documentation.