Age: 26.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Electrocardiogram PR shortened, Enterovirus test negative, Eosinophil percentage decreased, Exposure to SARS-CoV-2
Clinical narrative: Office Visit  9/29/2021   Family Medicine -   Physician Family Medicine Moderate persistent asthma with exacerbation  Dx Cough ? Shortness of Breath ? Headache    Reason for Visit Progress Notes  (Physician) ? ? Family Medicine ? ? Encounter Date: 9/29/2021 ? ? Signed Diagnoses and all orders for this visit:   Moderate persistent asthma with exacerbation -     promethazine-codeine (PHENERGAN with CODEINE) 6.25-10 mg/5 mL syrup; Take 5 mL by mouth every 6 (six) hours as needed  for cough  Other orders -     albuterol 2.5 mg /3 mL (0.083 %) nebulizer solution; Take 3 mL (2.5 mg total) by nebulization 4 (four) times a day as needed  for wheezing or shortness of breath  Continue prednisone and Omnicef.  Cough syrup for severe cough, chest wall pain.  Call back if any problems.  Off work 9/28?10/3.  HPI: Patient is an 26 y.o. female is here today for seen at PT FIRST on 9.4.21 treated for pneumonia then again on 9.27.2021 for unresolved pneumonia , currently on prednisone taper and a antibiotic.  Was told by patient's first, she get pneumonia/on x-ray, no record or report in the chart.  Did have a second x-ray 2 days ago, no report is seen in the computer??.  Subjective shortness of breath, severe cough, causing chest wall pain, cough headache.  Some sputum production.  On Omnicef and prednisone already.    ED to Hosp-Admission  Discharged 10/7/2021 - 10/10/2021 (3 days)  Hospital  COVID-19 virus infection  Principal problem  Hospital Course       Hospital Course:   26-year-old female past medical history significant for asthma major depressive disorder is admitted to the hospital because of acute hypoxic respiratory failure secondary to COVID-19 pneumonia.  She was started on remdesivir and Decadron.  Her oxygenation and shortness of breath improved and on day of discharge she was saturating on room air.   She had home oxygen evaluation on the day of discharge and she does not qualify for any home oxygen at discharge.   She is being discharged with instruction to follow-up with her family doctor within 1 week.  Chief Complaint Patient presents with ? Fever ? Shortness of Breath     1. COVID-19 infection?patient was diagnosed with COVID-19 couple days ago.  She had exposure from her mom approximately 10 days before that.  Patient has a very significant infiltrates on x-ray.  Patient will be admitted and placed on dexamethasone IV as well as a remdesivir.  Went to consult infectious disease to see if she warrants any additional treatment. 2. Acute hypoxic respiratory failure?patient's SPO2 went down to approximately mid 80s at home.  She has extensive infiltrates on x-ray.  A CT scan to rule out PE has been ordered.  Her D-dimer is elevated. 3. Asthma?she says her asthma is not very severe.  She has never been hospitalized for nor intubated.  History of Present Illness     Patient is an 26 y.o. female.    Comes in today with a complaint of low oxygen.  Patient has underlying history of asthma which seems to not be very severe.  1 month ago she developed a cough and was diagnosed with a pneumonia.  She was treated with a round of antibiotics with only modest improvement.  She was then placed on a neuro another round of antibiotics which she finished just recently.  Despite this she is not really feeling much better.  In addition her mother was found to be positive for Covid approximately 12 days ago.  She tried to stay as far away from them.  In addition the patient also Was vaccinated on 9/21/2021 (first round) which was a few days prior to exposure to her mom.  Today patient went to the bathroom and she noticed that her lips and fingers were blue.  She subsequently came into the emergency room for further evaluation.  She also notes chest pain with deep inspiration.  She denies any leg swelling or calf pain.