Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Acute respiratory failure, Anticoagulant therapy, COVID-19 pneumonia, Chest X-ray, Chronic obstructive pulmonary disease
Clinical narrative: Patient:   74 y.o.    Admit Date:  7/24/2022   Discharge Date:   7/25/2022   Discharge Diagnosis:  Principal Problem:   Pneumonia due to COVID-19 virus Active Problems:   Acute respiratory failure with hypoxemia   Essential hypertension   Tobacco abuse   COPD with acute exacerbation   S/P redo sternotomy redo AVR (aortic valve replacement) # 21 mm bovine pericardial EF 60% (2/1/2018)     Hospital Course:  74 year old female with COPD was admitted with exacerbation and Covid-19 infection. She was started on antibiotics, steroids and Remdesivir. She has done well and will be discharged home today on Lovenox due to elevated d dimer. She had previously received the vaccine booster. Patient educated on appropriate level of care post-discharge. Follow up with Primary Care Doctor in 5-7 days.   Physical Exam on the day of discharge: Last Recorded Vital Signs: Temp: 97.6 °F (36.4 °C) Heart Rate (Monitor): 85 Pulse: 75 BP: 154/86 Respirations: 18 SpO2: 90 % O2 Flow Rate (l/min): 2 l/min General Appearance: no distress  Eyes: PERRLA ENT: moist mucus membranes, no adenopathy Lungs: clear to auscultation bilaterally  Heart: regular rate and rhythm Abdomen: soft, non-tender  Skin: No rashes or lesions  Extremities: full ROM Neuro: alert, normal strength and tone    Consults:  IP CONSULT TO SEPSIS NURSE NAVIGATOR   Significant Diagnostic Studies:   TTE, CXR   Operations: none   Disposition:  Home    Discharge Condition:  Fair    Discharge Medications:   Current Discharge Medication List   START taking these medications   Details cefdinir (OMNICEF) 300 mg capsule Take 1 Capsule by mouth Twice a day for 7 days. Qty: 14 Capsule, Refills: 0   Associated Diagnoses: Acute respiratory failure with hypoxemia   enoxaparin (LOVENOX) 40 mg/0.4 mL injection Administer 0.4 mL subcutaneously Once Daily for 7 days. Qty: 7 Each, Refills: 0   Associated Diagnoses: Pneumonia due to COVID-19 virus     CONTINUE these medications which have NOT CHANGED   Details sertraline (ZOLOFT) 100 mg tablet Take 1 Tablet by mouth Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Depression, unspecified depression type   latanoprost (XALATAN) 0.005 % Instill 1 Drop in both eyes At bedtime. Qty: 7.5 mL, Refills: 3   Associated Diagnoses: Other specified glaucoma, unspecified laterality   brimonidine (ALPHAGAN) 0.2 % ophthalmic solution Instill 1 Drop in affected eye(s) Twice a day. Qty: 15 mL, Refills: 3   Associated Diagnoses: Other specified glaucoma, unspecified laterality   potassium chloride (KLOR-CON) 10 mEq tab Take 1 Tablet by mouth Twice a day. Qty: 180 Tablet, Refills: 3   Associated Diagnoses: Acute diastolic CHF (congestive heart failure)   metoprolol (LOPRESSOR) 50 mg tablet Take 1 Tablet by mouth Twice a day. Qty: 180 Tablet, Refills: 3   Associated Diagnoses: Essential hypertension   Ferrous Sulfate (IRON, FERROUS SULFATE,) 325 mg (65 mg iron) tablet Take 1 Tablet by mouth Twice a day. Qty: 180 Tablet, Refills: 3   Associated Diagnoses: Iron deficiency anemia secondary to inadequate dietary iron intake   ipratropium-albuteroL (DUONEB) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulizer solution Take 3 mL by nebulization Every 6 hours. Qty: 270 mL, Refills: 3   Associated Diagnoses: Chronic obstructive pulmonary disease, unspecified COPD type   furosemide (LASIX) 40 mg tablet Take 1 Tablet by mouth Twice a day. Qty: 180 Tablet, Refills: 5   Associated Diagnoses: Acute diastolic CHF (congestive heart failure)   ibuprofen (MOTRIN) 800 mg tablet Take 1 Tab by mouth Twice a day. Qty: 60 Tab, Refills: 3   Associated Diagnoses: Arthralgia, unspecified joint   LORazepam (ATIVAN) 0.5 mg tablet Take 1 Tab by mouth Every 12 hours as needed. Qty: 60 Tab, Refills: 2   Associated Diagnoses: Anxiety   diphenoxylate-atropine (LOMOTIL) 2.5-0.025 mg per tablet Take 1 Tab by mouth Four times a day as needed for Diarrhea. Qty: 20 Tab, Refills: 0   Associated Diagnoses: Diarrhea, unspecified type   omeprazole (PRILOSEC) 40 mg DR capsule Take 1 Cap by mouth Daily. Qty: 30 Cap, Refills: 3   Associated Diagnoses: Epigastric pain   aspirin (ASPIRIN) 325 mg tablet Take 0.5 Tabs by mouth Daily. Qty: 15 Tab, Refills: 11   Associated Diagnoses: Severe aortic stenosis by prior echocardiogram; S/P AVR (aortic valve replacement)   cyanocobalamin 100 mcg Take 100 mcg by mouth Daily.   Associated Diagnoses: Essential hypertension; White coat hypertension; Mixed hyperlipidemia; S/P AVR (aortic valve replacement)   loratadine (CLARITIN) 10 mg tablet Take 1 Tab by mouth Daily. Qty: 90 Tab, Refills: 3   Associated Diagnoses: Seasonal allergic rhinitis due to pollen   Ranitidine HCl 150 mg Cap Take 1 Cap by mouth Twice a day. Qty: 180 Cap, Refills: 3   Associated Diagnoses: Gastroesophageal reflux disease without esophagitis   albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler Take 2 Puffs by inhalation Every 4 hours as needed. Qty: 1 Package QS, Refills: 0   Associated Diagnoses: Wheezing; COPD (chronic obstructive pulmonary disease)   CALCIUM CARBONATE/VITAMIN D3 (CALCIUM + D PO) Take 1 Tab by mouth TWICE A DAY.   Multivitamin Tab Take 1 Tab by mouth DAILY.   VITAMIN E ACETATE (VITAMIN E PO) Take 1 Tab by mouth DAILY.