Age: 86.0
Sex: F
Vaccine: COVID19
Symptoms: Cardiac failure acute, Cardiac failure congestive, Chest X-ray abnormal, Chills, Chronic obstructive pulmonary disease
Clinical narrative: Hospitalized (3.21.22 - 3.23.22); COVID-19 positive (3.21.22); fully vaccinated PLUS Booster -pfizer x3 D/c Summary:Discharge Summary BRIEF OVERVIEW: Discharge Provider: withheld Primary Care Provider at Discharge: withheld Admission Date: 3/21/2022 Discharge Date: 3/23/2022 Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 virus infection 03/21/2022 Yes ? COPD (chronic obstructive pulmonary disease)  09/24/2015 Yes ? Sarcoidosis- Stage II 03/20/2015 Yes Resolved Hospital Problems   Diagnosis Date Noted Date Resolved POA ? Chronic respiratory failure with hypoxia  05/27/2020 03/23/2022 Yes ? Acute on chronic diastolic congestive heart failure    Active Issues Requiring Follow-up Issue:  COVID-19 infection Recommended follow-up provider/specialty:  PCP What is needed:  Follow-up to ensure resolution of symptoms DISCHARGE DISPOSITION: Home without services DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: COVID-19 virus infection  COVID-19  Acute respiratory disease due to COVID-19 virus    HOSPITAL COURSE: Patient is a 86 y.o. female who presents today for COIVD 19 brought in by her daughter.  She did not want to come in but her daughter found that she was significantly hypoxic at home and insisted she come in.  She has had these symptoms for the last 3 days getting significantly worse in the past 24hours.  In the ED she was positive for COVID 19 and persistently hypoxic so she was started on O2 and our service was contacted for admission..  Patient was admitted and started on dexamethasone therapy.  Renal function precluded the use of remdesivir.  She stabilized and we were able to wean her off supplemental oxygen over the next 2 days.  She was able to ambulate without the need for supplemental oxygen on the day of discharge.  She was subsequently discharged home to complete a Medrol Dosepak and isolate until 10 days from the 1st day of symptoms.  She can then return to activity as tolerated.  She is to resume her regular medications as previously ordered.  She can return to diet and activity as tolerated.  She is recommended to follow up with her primary care provider in the next 10-14 days to ensure complete resolution of her symptoms.  She understood all these instructions and was discharged home in stable condition. CONSULTS / RECOMMENDATION: None INPATIENT PROCEDURES: None   BP 131/84  | Pulse 93  | Temp 36.6 °C (Oral)  | Resp 18  | Ht 1.549 m  | Wt 63 kg  | SpO2 96%  | BMI 26.24 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:   General: She is not in acute distress.    Appearance: She is well-developed and well-nourished.  HENT:  Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Oropharynx is clear and moist. Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:    Extraocular Movements: Extraocular movements intact and EOM normal.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:    Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Intact distal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary: Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Chest: Breasts: No tenderness.  Abdominal:  General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no guarding or rebound.     Hernia: There is no hernia in the right inguinal area.  Musculoskeletal:     General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Lymphadenopathy:  Cervical: No cervical adenopathy.     Lower Body: No right inguinal adenopathy. No left inguinal adenopathy.  Skin:   General: Skin is warm and dry.     Findings: No rash.  Neurological:   Mental Status: She is alert and oriented to person, place, and time.     Deep Tendon Reflexes: Reflexes are normal and symmetric.  Psychiatric:      Mood and Affect: Mood and affect normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal   3/21/22 H&P: CHIEF COMPLAINT: COVID-19 virus infection ASSESSMENT / PLAN: * COVID-19 virus infection Assessment & Plan Patient is an 86-year-old female with past medical history of CHF, chronic obstructive pulmonary disease, sarcoidosis, hypertension, hyperlipidemia who presented to the emergency department with 3 days of worsening shortness of breath especially worse over the past 24 hours.  Her daughter was concerned about her breathing and brought for evaluation.  The patient states that she would not have sought medical care if her daughter had not insisted she come here.  She denies any chest pain, fever, productive cough, leg swelling, numbness, tingling, weakness.  Her work up in the ED was positive for COVID 19 pneumonitis.  She did not have fever.  Her CXR showed bilateral infiltrates.  She required 2L nc O2 and I was contacted by the ED staff for admission.  We are admitting her for respiratory support, remdesivir and steroid therapy.   Chronic respiratory failure with hypoxia  Assessment & Plan Patient on 2L as needed at home and requiring 2L continuously now.   Acute on chronic diastolic congestive heart failure  Assessment & Plan Patient is euvolemic.  Will monitor fluid status keeping her overall negative.  Will limit Na to 2000mg and fluids to 2000ml.   COPD (chronic obstructive pulmonary disease)  Assessment & Plan Not currently exacerbated.  Will continue inhalers as at home.  Steroids for COVID/COPD   Sarcoidosis- Stage II Assessment & Plan Stable. Chronic HISTORY OF PRESENT ILLNESS: Patient is a 86 y.o. female who presents today for COIVD 19 brought in by her daughter.  She did not want to come in but her daughter found that she was significantly hypoxic at home and insisted she come in.  She has had these symptoms for the last 3 days getting significantly worse in the past 24hours.  In the ED she was positive for COVID 19 and persistently hypoxic so she was started on O2 and our service was contacted for admission.. Review of Systems Constitutional:  Positive for chills and fatigue. Negative for fever and unexpected weight change.  HENT: Negative for hearing loss, sore throat and trouble swallowing.  Eyes: Negative for pain and visual disturbance.  Respiratory:  Positive for cough and shortness of breath. Negative for wheezing and sputum production.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for nausea, vomiting, diarrhea, blood in stool and trouble swallowing.  Genitourinary:  Negative for dysuria, frequency, urgency, vaginal bleeding and vaginal discharge.  Musculoskeletal:  Positive for joint pain. Negative for muscle pain.  Neurological:  Negative for headaches, dizziness, light-headedness, speech difficulty, numbness/tingling and weakness.  Endo/Heme/Allergy:  Negative for adenopathy.  Psychiatric/Behavioral:  Negative for depression and anxiety.  Skin:  Negative for itching, rash, wound and breast changes.  Breast: Negative for breast changes.  OBJECTIVE: BP 101/53  | Pulse 91  | Temp 36.3 °C (Oral)  | Resp 18  | Ht 1.549 m  | Wt 63 kg  | SpO2 95%  | BMI 26.24 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed.     Interventions: Nasal cannula in place.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no guarding or rebound.     Hernia: There is no hernia in the right inguinal area.  Musculoskeletal:        General: Deformity present. Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Lymphadenopathy:     Cervical: No cervical adenopathy.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Deep Tendon Reflexes: Reflexes are normal and symmetric.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.