Age: 67.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Hypoalbuminaemia, Illness, Klebsiella test positive, Loss of personal independence in daily activities, Lung opacity
Clinical narrative: Date of Admission Admit Date: Jan-26-2022  Date of Discharge Date of discharge Jan-31-2022  Allergies LITHIUM DERIVITIVES - Not Specified  Demerol - Not Specified  Depakote - Not Specified  Topamax - Not Specified  tape - Not Specified  LEVAQUIN - itching at IV site  Chief Complaint Shortness of breath  Final Diagnoses Urinary tract infectious disease  Acute COVID-19  Acute hypoxemic respiratory failure  Lab Results Jan-31-2022 0534 Point Of Care GLUSTX  173 Jan-31-2022 0425 Chemistry GLUCOSE  202BUN  18CREAT  0.6MDRD GFR  100NA  133K  5.1CL  98CALCIUM  8.3CO2  27.9OSMO  274.0ANION GP  12.2BUN/CRE  30.0 Jan-31-2022 0425 Hematology WBC  8.5RBC  4.82HGB  14.5HCT  42.9MCV  89.0MCH  30.1MCHC  33.8RDW  16.6RDWSD  53.5PLT  266MPV  10.1MANDIFF  YBAND %  1SEG %  86LYMPH %  5MONO %  4META %  2MYELO %  2NRBC%  0.2NRBC  0.0HGB/HCT  3.0 Jan-30-2022 1610 Point Of Care GLUSTX  307 Jan-30-2022 1125 Point Of Care GLUSTX  253 Imaging Results Chest radiograph 01/26/2022, per radiology report "IMPRESSION: Severe bilateral interstitial and airspace opacities consistent with pneumonia concerning for COVID-19. "  Functional Status* Activity of daily living - Needs assistance  Social History tobacco use Current Every Day Smoker, 30 yrs, Smoking Cessation Yes Currently smokes approximately 3 cigarettes per day (January 2022)  alcohol use No Known Use  drug use No Known Use  marital status Single  occupation Former EKG technician, currently disabled  general comment Lives were her son and his family in town.  Health Concerns Urinary tract infectious disease  Current Every Day Smoker, 30 yrs  Father Deceased Heart disease; Hypertensive disorder  Mother Deceased @ unknown age Heart disease; Hypertensive disorder  Tobacco Cessation* FDA Tobacco Cessation Medication has been prescribed (see discharge medications) (Nicotine patch)  Vital Signs Jan-31-2022 0400 T 97.8 HR     57 RR 20 BP   145 / 87 O2Sat 93 Jan-31-2022 0000 T 98.1 HR 63 RR 15 BP   128 / 64 O2Sat 94 PHYSICAL EXAM CONSTITUTIONAL: Patient Is a 67-year-old female who appears acutely and chronically ill but in no acute distress. She is resting in bed in the left lateral recumbent position.  CARDIOVASCULAR: Heart has regular rate and rhythm. No murmurs, rubs or gallops appreciated on auscultation. Pulses are 2+ in bilateral radial arteries with no lower extremity edema noted. Telemetry reveals sinus rhythm.  PULMONARY: Patient is wearing nasal cannula set at 4 L with associated SpO2 of 94%. On auscultation lung sounds remain coarse with diffuse end-expiratory wheeze noted in anterior and posterior lung fields. Deep inspiration also still elicits a cough. As patient gets up to use the bedside commode it also elicits coughing. She recovers within a couple of minutes sitting on the commode.   GASTROINTESTINAL: Abdomen is soft, nontender and nondistended. No rebound or guarding. Bowel sounds normoactive.  PSYCHIATRIC: Patient is alert and oriented to person, place, time, and situation. Affect remains flat, and mood is depressed.  Consultations Osteopathic manipulative medicine  Hospital Course Patient is a 67 year old female who was admitted for acute hypoxemic respiratory failure secondary to COVID pneumonia, and complicated urinary tract infection. She received 2 doses of the Moderna vaccine and had been symptomatic for the week prior to admission. Past medical history is significant for COPD, diabetes and schizoaffective disorder. Her total hospitalization was 6 days.   Patient's hospitalization was complicated by the diagnosis of urinary tract infection on admission. Patient was started on Bactrim for her UTI. Patient continued on dexamethasone throughout her hospitalization. Patient was noted to have diagnosis of COPD, but not have any COPD medications on her home med list. Patient was started on Dulera and Spireva during her hospitalization with notable improvement in her oxygen requirements. She was also prescribed prn albuterol that she did not require while under our care. Her home valium for muscle spasms was also switched to cyclobenzaprine while hospitalized. On discharge she is requiring 3L supplemental oxygen continuously and will be discharged with home health.  Condition at Discharge Stable  Discharge Medications Atorvastatin Calcium Oral Tablet 40 MG 40 MG ORALLY ONCE A DAY busPIRone HCl Oral Tablet 10 MG 10 MG ORALLY 3 TIMES A DAY CYCLOBENZAPRINE HCL 5 MG ORALLY 3 TIMES A DAY AS NEEDED for MUSCLE SPASM (ePrescribed by RESIDENT on Jan-31-2022 1114) DEXAMETHASONE 6 MG ORALLY ONCE A DAY (ePrescribed by RESIDENT on Jan-31-2022 1114) DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG 120 MG ORALLY EVERY MORNING Eliquis Oral Tablet 5 MG 5 MG ORALLY TWICE DAILY metFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 500 MG 1000 MG ORALLY TWICE DAILY MOMETASONE-FORMOTEROL 100/5 MCG/ACT 2 INH INHALATION TWICE DAILY PER RT (ePrescribed by RESIDENT on Jan-31-2022 1114) Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG 25 MG ORALLY ONCE A DAY Percocet Oral Tablet 10-325 MG 1 TAB ORALLY 3 TIMES A DAY ProAir Digihaler Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT 2 PUF INHALATION EVERY 4 HOURS AS NEEDED for SHORTNESS OF BREATH SEROquel Oral Tablet 200 MG 400 MG ORALLY DAILY AT BEDTIME TIOTROPIUM BROMIDE 2.5 MCG/ACT 2 INH INHALATION DAILY PER RT (ePrescribed by RESIDENT on Jan-31-2022 1114) Xanax Oral Tablet 1 MG 1 MG ORALLY 3 TIMES A DAY Discharge Disposition Discharge to home with home health  Plan Plan: -Sepsis (fever and tachypnea) secondary to COVID-19 -Acute hypoxemic respiratory failure secondary to COVID-19 pneumonia, requiring nasal cannula -Complicated urinary tract infection, urine culture 1/15/22 growing >100,000cfu Klebsiella resistant to cephalosporins -Hypoalbuminemia, secondary to acute illness and poor nutrition -COPD, noncompliant with home 2L supplemental oxygen -Essential hypertension, not currently on medications -Diabetes mellitus type II, poorly controlled, A1c 8.1 on admission -Hyperlipidemia -History of DVT, bilateral legs -History of recurrent UTIs and bladder surgery -Chronic back pain with sciatica -History of cervical and lumbar discectomies -Tobacco use, smokes 3 cigarettes/day -Schizoaffective disorder, per history -Anxiety disorder, unspecified -Insomnia, per history -Medical noncompliance  Plan: Patient is to be discharged home with home health (physical therapy). She will be discharged with 3L supplemental oxygen to be worn continuously.  She has an appointment scheduled with Dr. at health center on 02/07/2022 at 2pm to establish care.      DO, PGY-2  Primary Care Provider UNKNOWN PRIMARY CARE PHY  CHS  Electronically signed by  RESIDENT on Jan-31-2022 1116