Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Neutrophil percentage increased, Nucleated red cells, Obesity, Oedema peripheral, Oropharyngeal pain
Clinical narrative: Hospitalized (1.20.22 - 1.23.22); COVID-19 positive (1.20.22);  fully vaccinated PLUS Booster - pfizer x3 d/c summary: Discharge Summary                                    Admitting Service: Admission Date: 1/20/2022 Discharge Date: 01/23/2022   Admitting Diagnoses: Acute respiratory failure with hypoxia  Patient Active Problem List Diagnosis ? Family history of colon cancer ? Personal history of colonic polyps ? Anxiety ? Ankle swelling ? Shortness of breath ? Nausea ? Heartburn symptom ? Abdominal pain, unspecified site ? Constipation ? Rectal bleeding ? Muscle pain ? Paroxysmal atrial fibrillation  ? Hx of adenomatous polyp of colon ? Status post ablation of atrial fibrillation, 05/14 ? Status post ablation of atrial flutter, 05/14 ? Essential hypertension ? Moderate pulmonary hypertension  ? History of total left hip arthroplasty ? Lymphedema of left arm ? Bilateral lower extremity edema ? Obesity (BMI 30-39.9) ? Gastric ulcer ? Hypercholesterolemia ? Venous (peripheral) insufficiency ? Acute respiratory failure with hypoxia ? COVID-19 ? Respiratory failure with hypoxia     Discharge Diagnoses: Active Hospital Problems   Diagnosis Date Noted  ? Acute respiratory failure with hypoxia 01/20/2022 Yes ? COVID-19 01/20/2022 Yes ? Respiratory failure with hypoxia 01/20/2022 Unknown ? Essential hypertension 07/12/2017 Yes ? Moderate pulmonary hypertension  07/12/2017 Yes ? Lymphedema of left arm 07/12/2017 Yes ? Paroxysmal atrial fibrillation  04/01/2014 Yes ? Anxiety 02/05/2010 Yes   Resolved Hospital Problems No resolved problems to display. CONDITION ON DISCHARGE: Stable and improved PROCEDURES:  none   CONSULTATIONS:  none   Details of Hospital Stay PRESENTING PROBLEM:  Respiratory failure with hypoxia [J96.91]   HOSPITAL COURSE:   Pt. is a 79 y.o. female with past medical history significant for paroxysmal atrial fibrillation, hypertension, hyperlipidemia, venous insufficiency, breast cancer, left upper extremity lymphedema who presents today with fatigue and weakness.  The patient developed a sore throat and dry cough 1/18.  She complains of mild shortness of breath but no chest pain.  She is vaccinated with booster against COVID-19. In the emergency department, the patient was hypoxic requiring 4 L nasal cannula.  Baseline lab work showed WBC 10.64, hemoglobin 13.9, BUN 22, creatinine 0.95, glucose 119, NT proBNP 958, CRP 15.6.  COVID-19 PCR was positive.  Chest x-ray showed findings of mild CHF.  The patient received Tylenol and Decadron while in the ED. She will be admitted for further management.  Hospital course was mostly unremarkable, treated with remdesivir, dexamethasone, IV Lasix, shortness of breath improved oxygen requirement improved, evaluated by Pulmonary rehab qualified for 1 L oxygen at rest and 2 L with activity, doing well discharge home today in stable condition, instruction discussed in detail with patient she verbalized understanding.   PE ON DISCHARGE: BP 135/69  | Pulse 57  | Temp 36.5 °C (Oral)  | Resp 16  | Ht 1.702 m  | Wt 110.2 kg  | SpO2 95%  | BMI 38.05 kg/m²    Physical Exam Vitals reviewed.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Cervical back: Neck supple.     Right lower leg: Edema present.     Left lower leg: Edema present.  Skin:    General: Skin is warm and dry.     Findings: No rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.  Psychiatric:        Behavior: Behavior normal.   H&P: CHIEF COMPLAINT:  Acute respiratory failure with hypoxia ASSESSMENT / PLAN: COVID-19 pneumonia Acute hypoxic respiratory failure Acute CHF - Symptom onset: 1/18. Patient is fully vaccinated with booster - O2 stable on 4LNC. CXR shows findings of acute CHF; NTproBNP 953 - Admit to inpatient - Decadron 6mg x 10 days - Remdesivir x 5 days - Patient does appear fluid overloaded with noted 8lb weight gain since 11/21. Start IV lasix 20mg BID. Monitor daily weights/I+Os - Recent echo (12/2021) showed LVEF 69%, trace MR - Monitor daily weights/I+Os - Trend Covid 19 appropriate lab work  - Supportive care with anti tussives and anti emetics - Monitor respiratory status closely with continuous pulse oximetry    Left upper extremity lymphedema - Concern for possible cellulitis however no fever, leukocytosis with CRP minimally elevated - Will monitor closely for now. Pt hesitant to use antibiotics due to multiple allergies (however per review has tolerated ancef in the past) - Mark area of erythema for close monitoring   Hypertension - Stable, continue Cozaar, Toprol and Dyazide   Hyperlipidemia - Continue statin   Paroxysmal atrial fibrillation  - Continue Toprol XL and Eliquis   History of breast cancer status post lumpectomy, radiation and chemotherapy   DVT prophylaxis:  Eliquis Code status: Full code   Plan and assessment discussed with Doctor and reflect his input.   HISTORY OF PRESENT ILLNESS: Pt. is a 79 y.o. female with past medical history significant for paroxysmal atrial fibrillation, hypertension, hyperlipidemia, venous insufficiency, breast cancer, left upper extremity lymphedema who presents today with fatigue and weakness.  The patient developed a sore throat and dry cough 1/18.  The following day, the patient developed chills, subjective fever and fatigue.  The patient has chronic lymphedema of her left upper extremity and noticed the arm was more swollen and red than usual.  She states she has recurrent cellulitis of her left upper extremity and this happens 6-9 times a year .  She states in the past she does not use antibiotics and the redness improves with just Tylenol.  Today, the patient became diffusely weak, was unable to get off of the toilet after going to the bathroom at which time EMS was called.  The patient reports decreased appetite and nausea over the last few days.  She denies vomiting, abdominal pain or diarrhea.  She complains of mild shortness of breath but no chest pain.  She is vaccinated with booster against COVID-19   In the emergency department, the patient was hypoxic requiring 4 L nasal cannula.  Baseline lab work showed WBC 10.64, hemoglobin 13.9, BUN 22, creatinine 0.95, glucose 119, NT proBNP 958, CRP 15.6.  COVID-19 PCR was positive.  Chest x-ray showed findings of mild CHF.  The patient received Tylenol and Decadron while in the ED. She will be admitted for further management. Review of Systems Constitutional:  Positive for activity change, appetite change, chills, fatigue and fever (subjective).  HENT: Positive for rhinorrhea, sneezing and sore throat. Negative for congestion.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough and shortness of breath.   Cardiovascular:  Positive for leg swelling. Negative for chest pain.  Gastrointestinal:  Positive for nausea. Negative for vomiting, abdominal pain and diarrhea.  Genitourinary:  Negative for dysuria.  Musculoskeletal:  Positive for gait problem. Negative for falls.  Neurological:  Positive for dizziness, light-headedness and weakness.  Skin:        Left upper extremity swelling and redness OBJECTIVE: BP 107/52  | Pulse 70  | Temp 99.9 °F (37.7 °C) (Oral)  | Resp 26  | Wt 116.2 kg (256 lb 2.8 oz)  | SpO2 95%  | BMI 41.35 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is obese. She is not toxic-appearing.     Comments: Pleasant Caucasian elderly female  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Comments: Breathing comfortably on 4LNC Diminished breath sounds in bases bilaterally  Abdominal:     General: Abdomen is protuberant. Bowel sounds are normal.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:        General: Swelling (LUE is swelling from shoulder to fingers. Erythema from mid bicep to mid forearm. Arm is warm to touch) present.     Right lower leg: Edema (BLE edema with thickened skin and chronic venous stasis changes bilaterally) present.     Left lower leg: Edema present.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.