Age: 92.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Agitation, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy
Clinical narrative: Hospitalized (1.30.22 - 2.1.22); COVID-19 positive (1.30.22); Fully vaccinated -moderna x2 (Privacy), MD  Last attending ? Treatment team Acute respiratory failure with hypoxia (HCC)  Principal problem   Discharge Summary (Privacy), MD (Physician) ? ? General Medicine Expand All Collapse All  BRIEF OVERVIEW: Discharge Provider: (Privacy), MD Primary Care Provider: (Privacy), MD Admission Date: 1/30/2022 Discharge Date: Feb 1, 2022    Active Hospital Problems   Diagnosis Date Noted POA ? COVID 02/01/2022 Unknown ? Acute respiratory failure with hypoxia (HCC)   Discharge Disposition:  home or self care    Active Issues Requiring Follow-up:    1. COVID pneumonia/AHRF: Continue 1L NC with activity and follow up with PCP in 1-2 weeks to reassess oxygen needs. Complete 4 more days of decadron to complete 7 day course.   DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Hypoxia [R09.02]   HOSPITAL COURSE: The patient is a 93 yo female with PMH of CAD, CHF, and pAF who was admitted for acute hypoxic respiratory failure secondary to COVID pneumonia. She was started on decadron and remdesivir with improvement of her symptoms and hypoxia. She continued to improve and was discharged home on 1 L NC with activity per pulm rehab evaluation. She also was sent home with decadron to complete a total 7 day course of steroids. She received a total of three days of remdesivir. She was discharged home in stable condition.   CONSULTS / RECOMMENDATION:  Consult Orders (From admission, onward)   None BP 142/56  | Pulse 68  | Temp 36.4 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 66.7 kg  | SpO2 95%  | BMI 23.03 kg/m²    Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal  1/30/22 H&P:  CHIEF COMPLAINT: Hypoxia ASSESSMENT / PLAN:  #  Acute respiratory insufficiency: # Covid 19 infection:      - decadron, remdesevir      - lovenox      - monitor pulse ox      - procalc is pending.   # h/o CAD, CHF and PAF:     -cont home meds including eliquis.  # Hypothyroidism:      - cont levothyroxine  # DVT prophylaxis: on eliquis  # code status: DNAR per daughter Subjective    HISTORY OF PRESENT ILLNESS: The patient is a 93 y.o. female who presents today with complaints of soreness of throat and weakness. She started having symptoms about 5 days ago. She is hard of heating. Her appetite is ok. No pain. No shortness of breath. She denies abdominal pain. Her work up in ER showed she was hypoxia.  She is hard of hearing. She became little agitated and after few questions she did not want to answer and she asked me to leave. I talked to her daughter and she is DNAR.  Review of Systems Constitutional:  Negative for activity change, appetite change and chills.  HENT: Negative for congestion, rhinorrhea and sneezing.  Eyes: Negative for redness.  Respiratory:  Negative for cough, wheezing and shortness of breath.   Cardiovascular:  Negative for chest pain, palpitations and orthopnea.  Gastrointestinal:  Negative for heartburn, nausea and vomiting.  Genitourinary:  Negative for difficulty urinating, urinary incontinence and dysuria.  Musculoskeletal:  Negative for neck pain and back pain.  Neurological:  Negative for headaches, dizziness and light-headedness.  Skin:  Negative for itching and color change.  OBJECTIVE: BP 180/73  | Pulse 81  | Temp 37 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 66.7 kg  | SpO2 97%  | BMI 23.03 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress. HENT:     Head: Normocephalic.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.  Cardiovascular:     Rate and Rhythm: Normal rate.     Heart sounds: No murmur heard.    Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing.  Abdominal:     General: Abdomen is flat. There is no distension.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No swelling or deformity. Normal range of motion.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced.     Findings: No bruising.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.     Motor: No weakness.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.