Age: 86.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Neutrophil count normal, Neutrophil percentage increased, Oedema peripheral, Platelet count normal, Pleural effusion
Clinical narrative: Date of Admission Admit Date: Nov-30-2021  Date of Discharge Date of discharge Dec-01-2021  Allergies Phenergan - Not Specified  Chief Complaint Shortness of breath  Final Diagnoses COVID-19  Procedure(s) Performed None  Lab Results Dec-01-2021 0415 Chemistry GLUCOSE  175BUN  23CREAT  1.5MDRD GFR  33NA  140K  3.6CL  102CALCIUM  8.4ALK PHOS  125CO2  29.8AST  24ALT  16AST/ALT  1.5TL PROT  6.8ALBUMIN  2.5TBILI  0.5DBILI  0.2OSMO  287.3ANION GP  11.8BUN/CRE  15.3CRP  10.70 Dec-01-2021 0415 Hematology WBC  8.5RBC  3.61HGB  9.6HCT  30.7MCV  85.0MCH  26.6MCHC  31.3RDW  16.4RDWSD  50.9PLT  297MPV  9.6AUTONEU%  92.4AUTOLYM%  6.0AUTOMON%  0.8AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  7.9AUTOLYM#  0.5AUTOMON#  0.1AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.05IG%  0.6 Nov-30-2021 1737 Coagulation PT  31.0INR  3.1PTT  47.6 Nov-30-2021 1657 Chemistry GLUCOSE  158BUN  22CREAT  1.4MDRD GFR  36NA  140K  3.3CL  101CALCIUM  8.5ALK PHOS  137CO2  30.1AST  24ALT  16AST/ALT  1.5TL PROT  7.4ALBUMIN  2.8TBILI  0.5OSMO  286.0ANION GP  12.2BUN/CRE  15.7CRP  8.40LACTATE  1.20PROBNP  2791 Nov-30-2021 1657 Hematology WBC  9.7RBC  3.93HGB  10.3HCT  33.3MCV  84.7MCH  26.2MCHC  30.9RDW  16.3RDWSD  50.3PLT  310MPV  9.3AUTONEU%  83.3AUTOLYM%  9.8AUTOMON%  5.2AUTOEOS%  1.1AUTOBAS%  0.2AUTONEU#  8.1AUTOLYM#  1.0AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.1NRBC%  0.0NRBC  0.0HGB/HCT  3.2IG#  0.04IG%  0.4 Nov-30-2021 1657 Serology COVID  PosPROCALC  <0.05CVD1TEST  NCVDEMPHC  NCVDSYMP  YCVDSYMDT  UCVDHOSP  UCVDICU  UCVDRESID  NCVDPREG  N Imaging Results CXR: Mild bilateral consolidations, chronic left pleural effusion  Functional Status* Impaired mobility, Activity of daily living - Needs assistance  Mental Status* Normal Cognition  Social History alcohol use Liquor, Current Occasionally drinks on holidays  drug use No Known Use  marital status Widowed  Health Concerns Liquor, Current  Father Deceased Coal workers' pneumoconiosis @ 74 Gastric ulcer; Low blood pressure; Coal workers' pneumoconiosis  Father Deceased @ unknown age  Mother Deceased @ 68 Hypertensive disorder; Gallstone; Renal failure syndrome  Mother Deceased  Brother Alive 84y Diabetes mellitus; Malignant neoplasm of scalp and/or skin of neck; Degenerative disorder of macula  Sister Deceased @ 58 Amyotrophic lateral sclerosis  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Dec-01-2021 1016 T 97.7 HR 72 RR 20 BP       156  / 56 O2Sat 97 Dec-01-2021 0844 HR 74 BP       164  /     51  Dec-01-2021 0801 T 97.7 RR     24 O2Sat 93 PHYSICAL EXAM CONSTITUTIONAL:  Patient appears comfortable and in no acute distress, resting in PCU on 2 L NC  EYES: Non injected sclera.  ENT: Normal hearing. Moist mucus membranes.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, pulses are 2/2 in the upper extremities, trace edema noted in the LE, no jugular venous distension  RESPIRATORY:  Auscultation reveals breath sounds with wheezes to auscultation throughout, respiratory effort is non-labored  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended. Bowel sounds present and normoactive  SKIN:  No wounds or rashes appreciated on the head, arms, or legs  NEUROLOGICAL:  No gross neurological deficits noted, sensation is grossly intact  PSYCHIATRIC:  Patient is alert and oriented to person, place, time, and event. Patient's mood is euthymic, affect is appropriate. RASS of 0.  Hospital Course The patient is a 86 year old female that presents to the ED for shortness of breath. She is found to be COVID positive.  She came to the ED for worsening shortness of breath. Placed in observation overnight. Fully vaccinated. She has been stable on her home oxygen overnight and was started on a course of steroids for COVID-19.   We will discharge home to be with her son who also was diagnosed with COVID. Sent 5 day course of dexamethasone, mucinex, tessalon, for supportive care.  Condition at Discharge Stable  Discharge Medications allopurinol 300 mg tab 300 MG ORALLY ONCE A DAY amlodipine 5 mg tab 5 MG ORALLY ONCE A DAY atorvastatin 40 mg tab 40 MG ORALLY ONCE A DAY BUMETANIDE 1 MG ORALLY ONCE A DAY Dexamethasone Oral Tablet 6 MG 6 MG ORALLY ONCE A DAY (ePrescribed by DO RESIDENT on Dec-01-2021 1042) Ferrous Gluconate Tablet 324 (38 Fe) MG 324 MG ORALLY ONCE A DAY isosorbide mononitrate 20 mg tab 20 TAB ORALLY TWICE DAILY Jardiance Tablet 10 MG 10 MG ORALLY ONCE A DAY losartan 50 mg tab 50 MG ORALLY TWICE DAILY MiraLax Packet 17 GM 17 GM ORALLY ONCE A DAY Mucinex Oral Tablet Extended Release 12 Hour 600 MG 600 MG ORALLY TWICE DAILY (ePrescribed by DO RESIDENT on Dec-01-2021 1042) omeprazole 20 mg TbEC 20 MG ORALLY ONCE A DAY PreserVision AREDS 7,160-113-100 unit-mg-unit tab 1 TAB ORALLY ONCE A DAY Tessalon Perles Oral Capsule 100 MG 100 MG ORALLY TWICE A DAY AS NEEDED for COUGH (ePrescribed by DO RESIDENT on Dec-01-2021 1042) Vitamin D3 Capsule 25 MCG (1000 UT) 1000 IU ORALLY MON AND FRI warfarin 5 mg tab 1 TAB ORALLY ONCE A DAY Discharge Disposition Discharge to home  Plan Assessment: - HFpEF, chronic without acute decompensation, with left pleural effusion, echo, previous type 2 diastolic dysfunction 2017 - COVID-19 pneumonia, in a vaccinated patient - Hypoxia with exertion - Chronic atrial fibrillation, likely permanent status post pacemaker without rhythm control, CHADs-Vasc of 6 pts, on warfarin - Coumadin coagulopathy, supratherapeutic INR, 3.1 - Essential hypertension - Peripheral vascular disease status post stent - history of gout on allopurinol - Chronic kidney disease stage 4, baseline creatinine of ~1.7 - Hyperlipidemia, on atorvastatin - Iron deficiency anemia, on ferrous gluconate - History of GERD, on omeprazole - Osteopenia - Degenerative joint disease  Plan: Discharge home with the help of family.   Dexamethasone 6 mg daily for 3 more days  Follow up with PCP in 1-2 weeks.  Primary Care Provider