Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Anticoagulant therapy, Blood culture negative, Blood lactate dehydrogenase, C-reactive protein, COVID-19
Clinical narrative: Patient received COVID vaccine 4/29/21, tested positive for COVID 8/14/21  8/14/21: patient is a 62 y.o. male with no significant past medical history presents with mild shortness of breath, myalgias, cough, somnolence and poor appetite.  He was found to be significantly hypoxic while in the waiting room in the emergency department when his pulse ox was found to be 74%.  He was put on supplemental oxygen of 6 liters/minute by nasal cannula and his pulse ox improved to about 92%.  Currently he is on 60% FiO2 with high-flow nasal cannula an oxygen flow of 30 liters/minute.  Patient is a 62 y.o.  obese male with no significant past medical history presenting with shortness of breath, cough, myalgias for 6 days and severe hypoxemia.   Principal problem: Hypoxia Viral pneumonia with severe hypoxemia: 62-year-old male presenting with 6 day history of shortness of breath, myalgias, cough and severe hypoxemia likely due to viral pneumonia caused by COVID 19 infection.  COVID-19 pneumonia  chest x-ray shows diffuse bilateral infiltrates most likely due to COVID-19 pneumonia Intravenous dexamethasone 6 mg daily started in the emergency department COVID-19 PCR test is pending The patient is a candidate for intravenous remdesivir because of severe new onset hypoxemia Check CBC, CMP, CRP, LDH, ferritin, D-dimer with morning labs  Discharge Summary 9/1/21: Hospitalization Admit Date/Time: 8/14/2021 10:57 AM Admitting Attending:  Discharge Date: 8/28/21 Discharge Attending Physician: medical doctor PCP name and Address:  Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course Patient is a 62 y.o. male with a history of diabetes that presented with a 6 day history of myalgias, cough and poor po intake with new reports of shortness of breath.  Patient Received the Johnson and Johnson vaccine in April of 2021.  Upon arrival to ED was found to have an SpO2 of 74% on room air, and was placed on 6 liters nasal cannula.  His O2 requirements continued to increase requiring high flow nasal cannula. As a result he was started on Dexamethasone and remdesivir. He continued to have increasing O2 requirements and was transferred to the ICU for closer monitoring. He did not require intubation. Ultimately he completed a five day course of remdesivir as well as a ten day course of dexamethasone. He was able to tolerate wean of his supplemental O2 and tolerated 2 liters NC on the day of his discharge. His room air SPO2 was 88% with improvement to 93% on 2 liters NC. He will be provided with home O2 at the time of his discharge.    His hospitalization was complicated by a PE (CT scan 8/28/21) for which anticoagulation was started. He was started on Apixaban 10mg po BID with plan to continue for ten days (last dose will be the evening dose on 9/4/21) prior to beginning Apixaban 5 mg BID for at least 3 months.    Additionally his hospitalization was complicated by Enterobacter Cloacae. (blood cultures on 8/27/21). He was started on Cefepime with plan to continue for seven days total. His repeat blood cultures have remained negative. Given his he is medically  appropriate for discharge otherwise we will transition to oral antibiotic therapy today and continue Bactrim for two more days to complete the total antibiotic course.    The patient's blood sugars were poorly controlled on admission (HgbA1C was 14). Insulin adjustments were made. His blood pressure was also poorly controlled on admission but with medication adjustments improved. The patient declined insulin  plus Metformin ER recommendations at discharge. Given this he will be discharged on Metformin ER plus trulicity (PA was obtained by pharmacy). Diabetes educators were consulted for assistance with diabetic teaching. It is strongly recommended that the patient follow up with primary care for ongoing management.    Lastly, the patient was noted to have incidental findings of thyroid and pancreatic masses on CT imaging. Given his COVID positive status and other acute medical conditions MRI was not obtained as an outpatient. It is strongly recommended that he follow up with his PCP for ongoing workup in addition to all age appropriate cancer screenings.    The patient was evaluated by PT/OT and deemed appropriate for home with assistance. He was evaluated by internal medicine on am rounds and deemed appropriate for discharge home. He will be provided a referral for a PCP at discharge (order placed in system). The patient is aware of his upcoming discharge and is agreeable with the discharge plan of care.