Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Diarrhoea, Dizziness, Dyspnoea, Dyspnoea exertional, Electrocardiogram
Clinical narrative: Hospitalized (3.20.22 - 3.21.22); COVID-19 positive (3.20.22); fully vaccinated PLUS Booster - pfizer x3 d/c summary:  Discharge Summary MD (Physician) ? ? Hospitalist  BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: MD Admission Date: 3/20/2022 Discharge Date: Mar 21, 2022   Code Status: Full code    Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 03/21/2022 Yes ? Pneumonia   Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:   Covid-19 Pneumonia with superimposed bacterial pneumonia COPD exacerbation due to above -Follow up with PCP Humira was held for 1 week and he was sent home with 5 more days of Omnicef after 2 days of ceftriaxone in the hospital. He also had 2 days of Azithromycin 500mg and was sent 1 more dose of 500mg to take tomorrow to complete his course.    Pending Labs    Order Current Status   Legionella Antigen, Urine In process   Streptococcus Pneumoniae Antigen, Urine In process   Peripheral Blood Culture Preliminary result   Peripheral Blood Culture Preliminary result   Sputum Culture Preliminary result    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pneumonia of right middle lobe due to infectious organism [J18.9] Sepsis, due COVID-19 pneumonia with superimposed bacterial pneumonia    HOSPITAL COURSE: Patienti s a 59 year old man with history of COPD, Hx of lung cancer and rheumatoid arthritis on Humira who presented to the hospital with 1.5 weeks from shortness of breath and a couple days of cough that was productive. He started becoming increasingly fatigued and decided to come to the hospital for evaluation. Chest x-ray showed a lobar pneumonia and he was started on ceftriaxone and azithromycin. Initial rapid COVID-19 test was negative but his Film Array PCR resulted as positive for COVID-19. He was Continued on prednisone for COPD exacerbation caused by COVID-19 pneumonia with superimposed bacterial pneumonia. He also held his Humira which he takes weekly on Sundays. His last dose was 3/13. I instructed him to hold off on this weeks dose and to restart on 3/27. Patient is otherwise feeling well and wanted to be discharged home. Humira was held for 1 week and he was sent home with 5 more days of Omnicef after 2 days of ceftriaxone in the hospital. He also had 2 days of Azithromycin 500mg and was sent 1 more dose of 500mg to take tomorrow to complete his course. He was also sent 3 days of prednisone 40mg daily after having two days of prednisone in the hospital to complete a 5 day burst.  CONSULTS / RECOMMENDATION: Consult Orders (From admission, onward)   None   INPATIENT PROCEDURES: BP 140/81  | Pulse 95  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.778 m  | Wt 104.3 kg  | SpO2 95%  | BMI 32.99 kg/m²    Physical Exam Constitutional:     General: He is not in acute distress.    Appearance: He is well-developed. He is not diaphoretic.  HENT:    Head: Normocephalic.  Eyes:    General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard.   No friction rub. No gallop.  Pulmonary:    Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Abdominal:    General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:    Right lower leg: No edema.     Left lower leg: No edema.  Skin:   General: Skin is warm.     Findings: No rash.  Neurological:    Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:       Mood and Affect: Mood normal.        Behavior: Behavior normal.   3/20 H&P:  HISTORY AND PHYSICAL   DATE OF DICTATION:  03/20/2022 ADMISSION DATE:  03/20/2022   CHIEF COMPLAINT Shortness of breath.   HISTORY OF CHIEF COMPLAINT A 59-year-old gentleman with COPD and remote history of lung cancer, who started feeling like he could not breathe about 1-1/2 weeks ago.  He describes it as feeling like he could not get enough air in.  He used his rescue inhaler, which would help if he was at rest, but he still had significant dyspnea on exertion.  He developed a cough productive of gray sputum, temp up to 100, nausea, had some midsternal chest pain.  Yesterday, he had diarrhea, but it was after he drank a lot of apple juice.  Has had a sore throat on and off, but nothing that is persistent.  His breathing issues have progressed and he says he has been on the couch for the last 2 days.  Finally, he was convinced to come to the ER today for evaluation.    Workup revealed right middle lobe pneumonia.  He received Zithromax, Rocephin, Solu-Medrol, albuterol, DuoNeb, 2 L in the ER REVIEW OF SYSTEMS EYES:  Denies diplopia, scotomata, amaurosis.  EARS:  Denies tinnitus, pain, and discharge.  NOSE:  Denies sinusitis, epistaxis, or fracture.  THROAT AND MOUTH:  Occasional sore throat over the last week and a half.  No dysphagia or odynophagia.  CARDIAC:  Some midsternal chest pain secondary to dyspnea.  No prior history of MI.  RESPIRATORY:  See HPI.  GI:  Has chronic nausea.  No vomiting, diarrhea, constipation, or bright red blood per rectum.  GU:  Denies dysuria, hematuria, and pyuria.  NEUROLOGIC:  Denies seizures, stroke, and syncope.  He has had the occasional headache and lightheaded feeling since he has been sick.  DERMATOLOGIC:  No open rashes, lesions, or sores.  ENDOCRINE:  No unintentional weight loss.  He did have sweats when he was sick.  PSYCHIATRIC:  No issues with depression or anxiety.   PHYSICAL EXAMINATION VITAL SIGNS:  Temperature 36.8, pulse 89, respirations 16, blood pressure 156/86, SpO2 of 97% on room air.  GENERAL:  A 59-year-old male who is alert and oriented x3.  No acute distress.  HEENT:  Head is normocephalic, atraumatic.  Eyes:  Pupils equal, round, reactive to light and accommodation.  Extraocular muscles intact.  Ears:  TMs are clear.  Nose:  Septum is midline.  Oropharynx is clear.  Mucous membranes mildly dry.  NECK:  Supple.  No adenopathy, carotid bruit, or thyromegaly.  HEART:  Regular rate and rhythm.  No S3, S4, or murmur.  LUNGS:  A few crackles in the bilateral lungs.  No expiratory wheezes.  ABDOMEN:  Soft, obese, nondistended, nontender.  No guarding, rebound, rigidity, masses, or bruits.  PSYCHIATRIC:  Calm and cooperative.  NEUROLOGIC:  Cranial nerves 2 through 12 intact.  No focal deficits.  MUSCULOSKELETAL:  Strength 5/5, upper and lower extremities bilaterally.  DERMATOLOGIC:  Skin changes consistent with psoriasis of the nails, right arm, and right leg.   LABORATORY DATA Electrolytes normal.    Renal function normal.    Glucose 109.    BNP 35.    Troponin 16.    Lactic acid 0.9.    Procalcitonin 0.07.    White count 13.9, hemoglobin 14.3, platelets 188.    Influenza negative.    COVID negative.    Chest x-ray:  Right middle lobe infiltrate.    EKG personally reviewed and interpreted:  Sinus rhythm.  No ischemic changes.   IMPRESSIONS AND PLAN 1. Acute community-acquired right middle lobe pneumonia.  Zithromax and Rocephin. 2. Acute exacerbation of chronic obstructive pulmonary disease.  Received 125 mg Solu-Medrol in the ER.  We will treat with prednisone 40 mg daily, DuoNebs q.i.d., Symbicort, and Spiriva (which will substitute for Trelegy). 3. Hypertension.  Continue lisinopril 40 mg daily and verapamil SR 240 mg nightly. 4. Hyperlipidemia.  Continue Pravachol 20 mg daily. 5. Rheumatoid arthritis.  The patient is on Humira and was scheduled for a dose today.  This will be held while he is ill. 6. Psoriasis. 7. Chronic low back pain.  Uses Flexeril p.r.n. 8. Remote history of lung cancer.  Status post right lower lobe lobectomy. 9. History of gastroesophageal reflux disease.  On no medications, but we will add Protonix since I am giving him steroids. 10. Deep vein thrombosis prophylaxis:  Lovenox. 11. Code status:  Full code (would not want to be kept alive in a persistent vegetative state).