Age: 75.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Cortisol decreased, Cough, Creatinine renal clearance decreased, Dyspnoea
Clinical narrative: Hospitalized (1.17.22 - 1.24.22); COVID-19 positive (1.17.22-self reported/home test); fully vaccinated PLUS Booster -pfizer x3 D/c summary:Discharge Summary (Privacy), FNP (Nurse Practitioner) ? ? General Medicine Cosign Needed Expand All Collapse All Discharge Summary BRIEF OVERVIEW: Discharge Provider: (Privacy), DO Primary Care Provider at Discharge: (Privacy), DNP, A-GNP Admission Date: 1/17/2022 Discharge Date: 1/24/2022  Active Hospital Problems   Diagnosis Date Noted POA ? Pneumonia due to COVID-19 virus 01/17/2022 Yes ? Obesity, Class II, BMI 35-39.9 07/07/2016 Yes ? Obstructive sleep apnea   Yes ? Paroxysmal atrial fibrillation (HCC) 03/25/2014 Yes ? Hypertension 03/25/2014 Yes   Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Acute respiratory failure with hypoxia (HCC)    DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory failure (HCC) [J96.00] Hypoxia [R09.02] COVID-19 virus infection [U07.1] Pneumonia due to COVID-19 virus [U07.1, J12.82]   HOSPITAL COURSE: The patient is a 76 y.o. male who presents to Emergency Department with increasing cough shortness of breath and COVID positivity at home. Patient described a month long history of increasing cough. He saw his PCP on Friday of this week on 01/14 and was started on home O2, antibiotics and steroids. However, patient noticed over the next several days he had increase in coughing paroxysms with increasing blood in sputum with left rib pain with coughing. Pain is sharp stabbing and worse with deep breathing and coughing. He has mild intermittent exertional dyspnea he denied anterior chest pain, dizziness, lightheadedness and has mild nausea. He denied abdominal pain, constipation, diarrhea, urinary signs or symptoms. COVID positive with room air sat of 88%. Chest x-ray demonstrated bilateral COVID pneumonia. Plan admission for supplemental O2 and COVID-19 protocol with albuterol MDI's and steroids. He was not started on remdesivir since he has had symptoms for almost 30 days.   Patient required 2L 02 on admission with increased work of breathing and persistent dry cough. He was treated with dexamethasone and further symptom management.  CT Thorax due to worsening hypoxia that showed mild bilateral pulmonary opacities consistent with COVID-19 pneumonia. No PE.  The patient struggled with dry persistent coughing paroxysms. Finished course of Omnicef and azithromycin. With aggressive pulmonary toileting his cough became more productive and he was able to be weaned off oxygen to room air.  Walk sat trial demonstrated no further need for supplemental oxygen as he remains stable on room air while sitting and walking.  Patient's metoprolol was held throughout his admission secondary to bradycardia and low normal blood pressures.  He was discharged home in stable with a prescription for 3 more days of dexamethasone and Tessalon Perles.  He was instructed to cut his metoprolol down to 25 mg daily, take his blood pressure and heart rate 2 times a day recording it in a journal.  He was also instructed to bring the journal to his follow-up appointment with PCP in 3-5 days to re-evaluate metoprolol dose.  He has a follow-up appointment in March with his cardiologist.  All questions and concerns were addressed prior to discharge. CONSULTS / RECOMMENDATION: none   INPATIENT PROCEDURES: none   BP 125/62  | Pulse 60  | Temp 36.6 °C (Oral)  | Resp 19  | Ht 1.702 m  | Wt 118.2 kg  | SpO2 97%  | BMI 40.81 kg/m²  FIO2 (%): 21 % Physical Exam Vitals reviewed.  Constitutional:      General: He is awake. He is not in acute distress.    Appearance: He is morbidly obese. He is not ill-appearing.  Neck:     Comments: No JVD Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Normal range of motion.     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal. Behavior is cooperative  1/17/22 H&P: History and Physical  HOSPITALIST                                            Chief complaint Increasing cough, COVID positive test at home today   Problem List Principal Problem:   Acute respiratory failure (HCC) Active Problems:   Acute respiratory failure with hypoxia (HCC)   Pneumonia due to COVID-19 virus   Hypertension   Paroxysmal atrial fibrillation (HCC)   Obstructive sleep apnea   Obesity, Class II, BMI 35-39.9 Assessment and Plan Medical Decision Making Patient seen evaluated in room 309 on med surge unit at the hospital.  Patient's pulse ox at home was 88% on arrival on room air is placed on 2 L nasal cannula.  Patient will be continued on COVID-19 protocol as directed he will not be started on remdesivir since he has had symptoms for almost 30 days.  However his symptoms did markedly worsened in the last 7-10 days prompting a visit to his PCP on Friday 4 days prior to arrival to the hospital today.  Patient does state that he had mild blood-tinged sputum yesterday which increased today.   Acute respiratory failure with hypoxia (HCC) Assessment & Plan Patient has had symptoms for a month has been on steroids azithromycin and Omnicef over the last 30 days and not improving currently is COVID positive with room air sat of 88% will plan on supplemental O2 and COVID-19 protocol with albuterol MDI's.  Chest x-ray demonstrates bilateral COVID pneumonia.   Pneumonia due to COVID-19 virus Assessment & Plan Patient presents with hypoxic respiratory failure with COVID positivity pulse ox is 80% on room air currently is on 2 L. will plan on doing Decadron for 10 days however patient has had signs and symptoms for now almost 30 days therefore remdesivir will not be initiated.     Paroxysmal atrial fibrillation (HCC) Assessment & Plan Will continue on cardiac monitoring as well as oral anti coagulation including Eliquis 5 mg orally 2 times a day, as well as baby aspirin.   Hypertension Assessment & Plan Continue home antihypertensives.  Obstructive sleep apnea Assessment & Plan Will continue supplemental O2 may use home CPAP if available.  Otherwise hospital CPAP or BiPAP if necessary.   Obesity, Class II, BMI 35-39.9 Assessment & Plan Will encourage weight loss diet and counseling.   History of Present Illness The patient is a 76 y.o. male  who presents to Emergency Department with increasing cough shortness of breath and COVID positivity at home.  Patient describes a month long history of increasing cough he saw his PCP on Friday of this week on 01/14 and was started on home O2, antibiotics and steroids.  However patient noticed over the next several days he had increase in coughing paroxysms yesterday had slight blood-tinged sputum otherwise clear today he had increasing blood in sputum with left rib pain with coughing.  Pain is sharp stabbing and worse with deep breathing and coughing.  He has mild intermittent exertional dyspnea he denies anterior chest pain dizziness lightheadedness he has mild nausea.  He denies abdominal pain constipation diarrhea urinary signs or symptoms. Objective BP 130/58  | Pulse 60  | Temp 36.6 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 118.2 kg  | SpO2 97%  | BMI 40.81 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is obese. He is ill-appearing.     Comments: Patient seen examined with nursing staff present.  Patient having several coughing paroxysms during examination.  Dry nonproductive.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Mouth/Throat:     Mouth: Mucous membranes are dry.  Eyes:     General: No scleral icterus.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: No respiratory distress.     Comments: Decreased bilateral bibasilar breath sounds also decreased right-sided greater than left. Chest:     Chest wall: No tenderness.  Abdominal:     General: There is no distension.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.     Comments: Obese but nontender.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Comments: Patient is ambulating in room without difficulty.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.