Age: 60.0
Sex: F
Vaccine: UNK, COVID19
Symptoms: Fatigue, Full blood count, General physical condition abnormal, Globulin, Glomerular filtration rate normal
Clinical narrative: 2/3/22 61-year-old female who presents to the emergency department due to concerns of Covid exposure and some mild shortness of breath for the past day.  She reports that she has been experiencing generalized body aches and a mild cough.  No pain with deep inspiration.  No pain on exertion.  Does report of a mild nonproductive cough.  She is vaccinated against COVID-19.  She has been monitoring her blood sugars, 300 while in the waiting room.  She reports that she is usually around this number daily.  Patient was noted to be lethargic in the emergency department and brought back to the room.  Her blood sugar was noted to be 61 and she was given apple juice.  Does report a mild headache.  No neck pain. No sore throat.  No abdominal pain.  No nausea vomiting.  No discomfort with urination. REVIEW OF SYSTEMS      Review of Systems  Constitutional: Positive for chills and fever.  HENT: Negative.  Negative for congestion, sinus pain and sore throat.   Respiratory: Positive for cough. Negative for shortness of breath and wheezing.   Cardiovascular: Negative.  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Negative.  Negative for abdominal pain, constipation, diarrhea, nausea and vomiting.  Genitourinary: Negative.  Negative for difficulty urinating and dysuria.  Musculoskeletal: Positive for arthralgias. Negative for back pain and neck pain.  Skin: Negative.  Negative for rash.  Neurological: Positive for headaches. Negative for dizziness, tremors, seizures, syncope, speech difficulty, weakness, light-headedness, numbness and memory loss.   2/7/22-Admission to another hospital: 61 y.o. female with a history of diabetes mellitus, hypertension, GERD, RA and neuropathy that presents to clinic complaining of weakness and disorientation. She was noted to be found by her granddaughter. Patient was in the bathroom and leaning over her sink for quite some time. When assessed by her family, mainly her granddaughter, she was noted to be weak and confused. She was able to ambulate with her family from the bathroom to place her she could sit down. She was noted to be disoriented, therefore family called EMS to evaluate. Patient was noted to be hypoxic upon EMS arrival. She was then transported to clinic for further evaluation. Patient does not remember anything prior to EMS arriving there. Events after EMS arrived are still unclear to an extent according to patient. Patient states that she was diagnosed with COVID-19 on Friday 02/04/2022. Friday is also the day that her symptoms began. Patient is vaccinated and boosted for COVID-19. Patient was placed on supplemental oxygen in the emergency department and given IV Decadron. Oxygen saturation improved and patient was able to be weaned off of supplemental oxygen. Patient reports a productive cough, headache, fever, chills and weakness. Patient ill-appearing but in no acute distress during exam. Plan of care reviewed with patient and she is agreeable.   1.COVID-19 pneumonia, patient was initiated on dexamethasone and she is not requiring any oxygen at this point. She was also on remdesivir which has been discontinued. She is on room air and does not have any specific complaints today and denies any shortness of breath therefore she is being discharged home in stable condition and she was advised to continue quarantining herself. No need to continue dexamethasone as an outpatient basis. 2. Hyponatremia, this has resolved now and sodium level is at 137. 3. Diabetes mellitus, resume home medications upon discharge. 4. Hypertension, on Coreg, losartan and amlodipine and will be continued. 5. Hyperlipidemia, on statins.  2/13/22 Admission to clinic 61-year-old female that presents the emergency department with worsening Covid symptoms.  Patient history was obtained through patient review and chart review.  Patient was positive for Covid on 2/3/2022 and was admitted to hospital for several days and then discharge.  Patient was feeling better and went home.  Patient states that she started feeling much worse today and progressively worsened.  Patient states that her symptoms are significant fatigue and weakness and fever with a T-max of 103 at home.  Patient is a former smoker denies any drug or alcohol use. Patient is alert and oriented x3 able to answer questions appropriately appears to be in no acute distress. Patient was admitted with post COVID-19 infection complication of generalized weakness, mild shortness of breath without hypoxia patient was admitted and treated with IV fluids and IV steroids with a gradual improvement.  Patient will be discharged with home health for physical therapy and close follow-up with a primary care physician as outpatient. 2/18/22  Discharge note: 61-year-old female that presents the emergency department with worsening Covid symptoms.  Patient history was obtained through patient review and chart review.  Patient was positive for Covid on 2/3/2022 and was admitted to hospital for several days and then discharge.  Patient was feeling better and went home.  Patient states that she started feeling much worse today and progressively worsened.  Patient states that her symptoms are significant fatigue and weakness and fever with a T-max of 103 at home.  Patient is a former smoker denies any drug or alcohol use. Patient is alert and oriented x3 able to answer questions appropriately appears to be in no acute distress. Patient was admitted with post COVID-19 infection complication of generalized weakness, mild shortness of breath without hypoxia patient was admitted and treated with IV fluids and IV steroids with a gradual improvement.  Patient will be discharged with home health for physical therapy and close follow-up with a primary care physician as outpatient.