Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Decreased appetite, Dyspnoea, Hypoxia, Lung infiltration
Clinical narrative: COVID Vaccine Breakthrough Case  Moderna Dose 1 2/16/21 Moderna Dose 2 3/16/21 COVID Positive 9/13/21 Hospitalized 9/13/21-9/15/21 Discharge to Home 9/15/21  Reason for Admission to Inpatient:  COVID pneumonia with hypoxia.  Patient awoke in the middle the night with chest congestion and generalized weakness.  She also reports she had some chills yesterday evening.  She arrived to the emergency department hypoxic with pulse oximetry of 86% on room air.  She was given a breathing treatment that did not improve this.  Patient required oxygen to bring her pulse oximetry into the 90s.  Patient is on 2 L of oxygen by nasal cannula.  Patient tested positive for COVID-19 and chest x-ray shows bilateral interstitial infiltrates consistent with viral pneumonia.  Patient will be admitted for IV remdesivir, dexamethasone and supplemental oxygen.   Allergies penicillins (Childhood,Rash,Itching)    Review of Systems: Constitutional:  Generalized weakness Eye: Negative ENMT: Negative Respiratory:  Chest congestion and hypoxia Cardiovascular: Negative Gastrointestinal: Negative Genitourinary:Negative Hema/Lymph: Negative Endocrine: Negative Musculoskeletal: Negative Integumentary: Negative Neurologic: Negative Psychiatric: Cooperative, alert and oriented   History of Present Illness:  Temperature 99.6  (11:00) Systolic Blood Pressure 110  (11:00) Diastolic Blood Pressure 55  (11:00) Pulse 65  (11:00) SpO2 97  (11:00) Respiratory Rate 20  (11:00)     Problem List/Past Medical History Breast cancer Hypercholesterolemia Hypertension Hypothyroidism Type 2 diabetes mellitus UTI - Urinary tract infection    Procedure History Appendectomy Mastectomy of left breast Cholecystectomy Tubal ligation    Social History Alcohol Details: Never Substance Abuse Details: Never Tobacco Details: Former smoker, year(s) 50.; Comment(s): quit 30 years ago    Medications Home Medications (15) Active acetaminophen 325 mg oral tablet 650 mg = 2 Tab, PRN, PO, Q4Hours aspirin 81 mg, PO, HS (At Bedtime) Dilaudid 2 mg, PRN, PO, Q6Hours dorzolamide-timolol ophthalmic 1 Drops, Eyes-Both, BID (Twice Daily) latanoprost ophthalmic 0.005% 1 Drops, Eyes-Both, HS (At Bedtime) letrozole 2.5 mg oral tablet 2.5 mg = 1 Tab, PO, Daily (Once Daily) Levemir 13 Units, SubQ, HS (At Bedtime) levothyroxine-Synthroid 100 mcg, PO, Daily (Once Daily) lisinopril 10 mg, PO, Daily (Once Daily) metformin 1,000 mg, PO, BIDWM (Twice Daily With Meals) Morphine Sulfate CR 15 mg, PO, Q12Hours omeprazole 20 mg, PO, Daily (Once Daily) simvastatin 40 mg, PO, HS (At Bedtime) Xanax 0.25 mg, PO, BID (Twice Daily) Zofran 8 mg, PRN, PO, Q8Hours    Lab Results No qualifying data available    Physical Examination: General: Alert and oriented, well nourished, no acute distress. Eye: PERRL, EOMI, normal conjunctiva. HENT: Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa, no scleral icterus, no sinus tenderness. Neck: Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy. Lungs: Clear to auscultation and percussion, non-labored respiration. Heart: Normal rate, regular rhythm, no murmur, gallop or edema. Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses. Musculoskeletal: Normal range of motion and strength, no tenderness or swelling. Skin: Skin is warm, dry and pink, no rashes or lesions. Neurologic: Awake, alert, and oriented X3, CN II-XII intact. Psychiatric: Cooperative, appropriate mood and affect.  Diagnostics:  Chest x-ray showed bilateral interstitial infiltrates consistent with viral pneumonia.   Impression and Plan: 1 COVID-19 pneumonia with hypoxia.  Patient will be treated with remdesivir and dexamethasone at supplemental oxygen. 2 comorbidities of metastatic breast cancer, hypercholesterolemia, hypertension, hypothyroidism, type 2 diabetes will be supportive with patient's baseline medications     rth Date: 07/20/1936   Admitting Diagnosis Diagnoses This Visit     COVID-19 (U07.1)   Discharge Diagnosis COVID-19 pneumonia with hypoxia   Associated Diagnoses: Co-Morbidities, complications   Hospital Course:  Uncomplicated   Reason for Hospitalization and Summary of Care Provided: Patient was admitted to the emergency department for COVID-19 pneumonia with hypoxia.  Patient was satting around 86% on room air which worsened with exertion. Patient required 2 L of oxygen by nasal cannula to maintain her oxygen saturations in the 90s initially.  She was admitted and placed on supplemental supportive oxygen.  She was given Decadron.  She was given remdesivir.  She improved significantly over the 1st day and has maintained oxygen saturation levels in the mid 90s over the past day. She feels much improved.  She does not feel weak any longer.  Her vital signs are stable and she feels well to be discharged home.   Labs/Radiology:  Home Medications (16) Active acetaminophen 325 mg oral tablet 650 mg = 2 Tab, PRN, PO, Q4Hours aspirin 81 mg, PO, HS (At Bedtime) Decadron 4 mg oral tablet 4 mg = 1 Tab, PO, Daily (Once Daily) Dilaudid 2 mg, PRN, PO, Q6Hours dorzolamide-timolol ophthalmic 1 Drops, Eyes-Both, BID (Twice Daily) latanoprost ophthalmic 0.005% 1 Drops, Eyes-Both, HS (At Bedtime) letrozole 2.5 mg oral tablet 2.5 mg = 1 Tab, PO, Daily (Once Daily) Levemir 13 Units, SubQ, HS (At Bedtime) levothyroxine-Synthroid 100 mcg, PO, Daily (Once Daily) lisinopril 10 mg, PO, Daily (Once Daily) metformin 1,000 mg, PO, BIDWM (Twice Daily With Meals) Morphine Sulfate CR 15 mg, PO, Q12Hours omeprazole 20 mg, PO, Daily (Once Daily) simvastatin 40 mg, PO, HS (At Bedtime) Xanax 0.25 mg, PO, BID (Twice Daily) Zofran 8 mg, PRN, PO, Q8Hours    Discharged to:  Home   Condition of Patient at Discharge (as compared to admission):  Improved, stable   Discharge Recommendations/Follow Up:  Quarantine for another 7 days or until 3 days after resolution fever and cough.  Follow-up with your PCP within 1 week after quarantine is over.  Signature Line  Electronically Signed By: MD  On 09.15.2021 11:42 AM  Electronically Signed By:   9/22/21: 85 yr old female with known covid pneumonia from her most current admission/discharge on 9/15-17 returns back continues to feel weak, SOB, cough, and pleuritic chest pain. She has left sided breast cancer, mastectomy, on chemo, has decrease appetite. no fevers. Transferred to hospital