Age: 28.0
Sex: M
Vaccine: COVID19
Symptoms: Blood alkaline phosphatase normal, Blood bilirubin decreased, Blood calcium decreased, Blood chloride increased, Blood creatinine normal
Clinical narrative: Name:  Age: 29 y.o. Admit Date: 7/17/2022  8:46 PM Discharge Date:  7/20/2022 Admitting Physician: Dr.  Discharge Physician: MD   Discharge Diagnosis: Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Muscular dystrophy   Partial epilepsy with impairment of consciousness   Acute respiratory failure with hypoxia   Friedreich's ataxia       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 29 y.o. male with a history of muscular dystrophy and Friedreich's ataxia. Limited mobility from above. Shortness of breath over past day brought on by respiratory infection, has had cough and shortness of breath. Nothing makes this better or worse. Some nausea. Some headache. To ED with above, O2 sats low here. "   Hospital Course: Patient, is a 29 y.o. male who presented with shortness of breath.  He was managed for the following:   * Pneumonia due to COVID-19 virus Pneumonia due to COVID-19 - Patient presented with shortness of breath.  He was initially placed on 2L NC.  He was started on remdesivir, decadron.  He was weaned to room air. He remained stable on room air and felt improved, was discharged home in stable condition.     Friedreich's ataxia - chronic, neurology evaluated patient during admission.  Follow-up outpatient.             Physical Exam on the Date of Discharge: Blood pressure 114/67, pulse 87, temperature 98.6 °F (37 °C), temperature source Oral, resp. rate 18, height 6' (182.9 cm), weight 88.5 kg (195 lb), SpO2 94 %. General - NAD, appears stated age HEENT - EOMI, PER, MMM,  Chest - lungs clear bilaterally, diminished Heart - RRR, NS1S2,  Abdomen - Soft, non-tender Extremities - warm,  Psych -affect appropriate Skin -dry   Discharge Condition: improved   Disposition: home   CONSULTS DURING ADMISSION:  IP CONSULT TO NEUROLOGY IP CONSULT TO SOCIAL WORK   IMAGING / PROCEDURES / RESULTS:     XR Portable Chest   Result Date: 7/17/2022 PROCEDURE INFORMATION: Exam: XR Chest Exam date and time: 7/17/2022 9:16 PM Age: 29 years old Clinical indication: Shortness of breath; Additional info: Suspected covid-19 TECHNIQUE: Imaging protocol: Radiologic exam of the chest. Views: 1 view. COMPARISON: CR XR PORTABLE CHEST 11/9/2020 8:10 PM FINDINGS: Lungs: Low lung volumes bilaterally. Mild atelectasis at the right lung base. No infiltrates are noted. Pleural spaces: No pleural effusion. No pneumothorax. Heart/Mediastinum: No cardiomegaly. Bones/joints: Unremarkable.    IMPRESSION: 1. Low lung volumes bilaterally. 2. Mild atelectasis at the right lung base. No infiltrates are noted. 3. There is no interval change from the prior examination. 4. No radiographic evidence of COVID-19 pneumonia. (Note: Imaging may be negative in the early stages of COVID-19 pneumonia.) THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 07/17/2022 10:03 PM   CT Chest Pulmonary Embolism W Contrast   Result Date: 7/18/2022 PROCEDURE INFORMATION: Exam: CTA Chest With Contrast Exam date and time: 7/18/2022 12:21 AM Age: 29 years old Clinical indication: Abnormal findings; Abnormal diagnostic tests; Elevated d-dimer; Fever and shortness of breath; Patient HX: SOB, fever, elevated d dimer of 469, covid19+, eval for pe. 59ml isovue 370, 20g RT ac, 3.5ml/sec, best images possible- hard for PT to follow breathing instructions. HX egj x2, muscular dystrophy. Ct2. Bi TECHNIQUE: Imaging protocol: Computed tomographic angiography of the chest with contrast. 3D rendering (Not supervised by radiologist): MIP and/or 3D reconstructed images were created by the technologist. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. Contrast material: ISOVUE 370; Contrast volume: 59 ml; Contrast route: INTRAVENOUS (IV);  COMPARISON: CR XR PORTABLE CHEST 7/17/2022 9:16 PM FINDINGS: Limitations: The study is limited by patient body habitus and respiratory motion artifact. There is also beam hardening artifact present, created by placement of the upper extremities within the scanning field. Pulmonary arteries: Pulmonary arteries are normal in caliber. No filling defects are demonstrated. No evidence of pulmonary embolism, within the technical limits of the examination. Aorta: The thoracic aorta appears unremarkable. No aneurysm or dissection demonstrated. Lungs: Nonspecific ground-glass infiltrates throughout both lungs. No consolidative pulmonary infiltrate noted. Pleural spaces: No pneumothorax. No pleural effusion. Heart: No cardiomegaly. No pericardial effusion. Lymph nodes: Unremarkable. No enlarged lymph nodes. Bones/joints: Degenerative changes of the thoracic spine noted. No acute osseous abnormality. Soft tissues: Unremarkable.    IMPRESSION: 1. The study is limited by patient body habitus and respiratory motion artifact. There is also beam hardening artifact present, created by placement of the upper extremities within the scanning field. 2. Nonspecific ground-glass infiltrates throughout both lungs. No consolidative pulmonary infiltrate noted. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 07/18/2022 12:49 AM           LABS AT TIME OF DISCHARGE:   Lab Results Component Value Date   WBC 6.0 07/20/2022   HGB 13.6 07/20/2022   HCT 41.0 07/20/2022   MCV 84.4 07/20/2022     Lab Results Component Value Date   SODIUM 142 07/20/2022   POTASSIUM 3.5 (L) 07/20/2022   MAGNESIUM 1.8 07/18/2022   CHLORIDE 111 07/20/2022   CO2 23 07/20/2022   GLUCOSE 141 (H) 07/20/2022   BUN 11 07/20/2022   CREATININE 0.9 07/20/2022   CALCIUM 7.9 (L) 07/20/2022   TBILIRUBIN 0.2 07/20/2022   ALP 44 07/20/2022   AST 12 07/20/2022   ALBUMIN 3.7 07/20/2022     Lab Results Component Value Date   INR 1.1 07/17/2022     Microbiology Results (last 14 days)    Procedure Component Value Units Date/Time   SARS-CoV-2, QL, PCR (Rapid) (Abnormal) Collected: 07/17/22 2101   Order Status: Completed Specimen: Throat Updated: 07/17/22 2150     SARS-CoV-2 RNA Detected      Comment:   Reference value:  Undetected   Testing was performed using the System.   Fact sheets for this Emergency Use Authorization (EUA) assay can be found at the following links:        Test Performed by: Lab Director: D.O.      Narrative:     Called to and read back, at 21:50 on 07/17/2022,  Symptomatic?->Yes Indications (select all that apply)->Close contact with COVID 19       MEDICATIONS AND ORDERS   Current Discharge Medication List   CONTINUE these medications which have NOT CHANGED   Details triamcinolone (KENALOG) 0.1 % cream Apply to skin irritation twice daily as needed Qty: 80 g, Refills: 5   Associated Diagnoses: Eczema, unspecified type   mupirocin (BACTROBAN) 2 % topical ointment Apply to affected area leg three times daily x 7 Qty: 22 g, Refills: 0   Associated Diagnoses: Abscess   baclofen (LIORESAL) 10 mg tablet Take 1 Tablet by mouth At bedtime. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Muscle spasm   diclofenac sodium (VOLTAREN) 1 % topical gel 2 g by Topical route Four times a day as needed. Qty: 3 Each, Refills: 1   Associated Diagnoses: Duchenne's disease   escitalopram oxalate (LEXAPRO) 20 mg Take 1 Tablet by mouth Every morning. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Mild recurrent major depression   gabapentin (NEURONTIN) 300 mg capsule Take 1 Capsule by mouth Three times a day. Qty: 270 Capsule, Refills: 0   Associated Diagnoses: Neuropathic pain   loratadine (CLARITIN) 10 mg tablet Take 1 Tablet by mouth Every evening. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Seasonal allergic rhinitis due to pollen   metFORMIN (GLUCOPHAGE) 1,000 mg tablet Take 1 Tablet by mouth Twice a day. Qty: 180 Tablet, Refills: 1   Associated Diagnoses: Insulin resistance   omeprazole (PRILOSEC) 20 mg DR capsule Take 1 Capsule by mouth Every evening. Qty: 90 Capsule, Refills: 1   Associated Diagnoses: Gastroesophageal reflux disease without esophagitis   Topiramate 200 mg Tab Take 200 mg by mouth Twice a day. Qty: 180 Tablet, Refills: 1   Associated Diagnoses: Partial epilepsy with impairment of consciousness   omega-3 fatty acids 300 mg Cap Take  by mouth Daily.     ERGOCALCIFEROL, VITAMIN D2, (VITAMIN D PO) Take 1,000 mg by mouth Daily.     Coenzyme Q10 100 mg Cap Take 400 mg by mouth At bedtime.     vitamin E (VITAMIN E) 1,000 unit Take 200 Units by mouth At bedtime.