Date of Admission: 9/8/2023   Date of Discharge: 9/10/2023   Issues to be Addressed at Follow-up: Multiple, see below   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/11/2023 to 9/11/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 PNEUMONIA   ? ACUTE RESPIRATORY FAILURE   ? MALIGNANT PLEURAL EFFUSION   ? CANCER METASTATIC TO BONE   ? FEMALE BREAST INFILTRATING LOBULAR CARCINOMA, LEFT UPPER-OUTER QUADRANT         11/22/2022  Noncompliant patient I recommended she gets her mammogram I have ordered a mammogram for her Nonfasting labs have been ordered     ? INTERSTITIAL LUNG DISEASE         8/31/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.   There is no specific diagnosis noted Reviewed her last pulmonary function test We will review her pulmonary function test-Order placed CT chest has been ordered     ? BRONCHIECTASIS   ? OBSTRUCTIVE SLEEP APNEA       Very severe OSA (AHI= 82) with severe O2 desaturations   ? ASTHMA, UNSPECIFIED   ? HTN (HYPERTENSION)     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions.   Hospital Course and Significant Findings: 70yo woman with hx of DM2, OSA, obesity, pituitary adenoma, ILD with restrictive mechanics on PFTs, bronchiectasis, left breast invasive breast adenoCA (HR+PR+) s/p simple mastectomy July 2019 with neg margins and neg sentinal LN biopsy. Taxol and herceptin was recommended at that time. She declined adjuvant chemotherapy and herceptin when she followed with Dr.    She was given abx 8/30 for cough for over a week which helped minimally. Then she developed a dry cough for about a week followed by shortness of breath for 2 days. She became very short of breath at her mammogram appt 9/8 and she was brought to the ED. In the ED she as found to be covid positive. CT chest unfortunately found evidence of left breast mass invading her pectoralis minor muscle, a mod/large left pleural effusion, and sclerotic metastases in the spine and manubrium. Her o2 sat was 91-94%. She was given remdesivir.    She felt much better after getting nebulizer treatments.  During her hospitalization she was never hypoxemic and remained without dyspnea.  During an oxywalk the afternoon of 9/10 she did have an O2 sat measured in the 80s but she reported no dyspnea.   COVID-19 PNEUMONIA (9/8/2023) and  ACUTE RESPIRATORY FAILURE (9/8/2023)   Assessment: Significant cough and cold symptoms for 2 weeks leading up to admission.  It is difficult to distinguish if she acquired COVID 2 weeks ago or more recently.  No fever.  She was given 2 doses of remdesivir   Plan: COVID rapid antigen test -9/10.  Done at bedside.  This suggest that her COVID infection was in the past and she is not acutely infected            Her resting SPO2 is 89 to 92% and she appears very comfortable.            I strongly suspect that she has a degree of chronic hypoxemic respiratory failure related to her pre-existing ILD, considering that she appears very comfortable.  Without dyspnea with borderline low O2 sats            I do not feel that she has respiratory failure due to COVID-19 infection            Home O2 ordered            She refuses steroids due to past adverse side effects with prednisone              BRONCHIECTASIS (11/10/2014) and   INTERSTITIAL LUNG DISEASE (9/7/2018) and  ASTHMA, UNSPECIFIED (9/18/2006)   Assessment: On home ciclesonide bid and atrovent and albuterol prn.   Plan: Alvesco            Atrovent every 4 hours while awake            Albuterol neb as needed            Home O2 as needed SPO2 88 or less -ordered for DME    FEMALE BREAST INFILTRATING LOBULAR CARCINOMA, LEFT UPPER-OUTER QUADRANT (6/19/2019) and  CANCER METASTATIC TO BONE (9/9/2023)   Assessment:  Left breast invasive breast adenoCA (HR+PR+) s/p simple mastectomy July 2019 with neg margins and neg sentinal LN biopsy. Taxol and herceptin was recommended at that time. She declined adjuvant chemotherapy and herceptin when she followed with Dr..  Now with signs and symptoms of breast cancer recurrence which is likely advanced and metastatic   Plan: Discussed with Dr. from oncology.  Will need repeat biopsies and oncology referral -E consults were sent            Discussed with Dr. from surgery, recommends outpatient breast radiologist consultation for biopsy -E consult was sent   MALIGNANT PLEURAL EFFUSION (9/8/2023)   Assessment: Effusion is likely due to adjacent malignancy.  With the current size I doubt this is causing respiratory failure.   Plan: Discussed thoracentesis, do not recommend at this time   HTN (HYPERTENSION) (11/1/2005)   Assessment: On home atenolol 12.5mg daily and  hctz 25mg daily   Plan: Atenolol            Hydrochlorothiazide   OBSTRUCTIVE SLEEP APNEA (6/15/2013)   Assessment: On home CPAP   Plan: CPAP while asleep   Primary Procedures:  none   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  COVID   Complications: none   Consults:  None Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code   --------------------------------------------   progress note:   Subjective: Daughter and sister at bedside.  Patient has no symptoms.  Coughing some but not bringing up any sputum.  Denies any shortness of breath walking around the room.  Somewhat limited in walking long ways chronically.  Chronic cough.  Discussed borderline low O2 sats.  Discussed due to her apparent comfort with borderline O2 sats, it is likely that she has pre-existing hypoxemia related to her ILD.  Recommended nebulizer treatments as needed.  Discussed her negative COVID test at bedside.  Discussed that this is likely indicative that she does not have new COVID but rather she had COVID when she started getting worsening cough symptoms over 2 weeks ago.  Later in the day discussed home O2 as needed for SPO2 less than 88% all in agreement.  Her sister is going to be a strong sponsor for her following through with malignancy work-up and recommendations for treatment.   Patient Vitals for the past 24 hrs:    Temp Temp Source Pulse BP Resp SpO2 O2 Delivery FiO2 (%) 09/10/23 1615 ? ? 75 ? 18 95 % RA ? 09/10/23 1605 ? ? 73 ? 18 95 % RA ? 09/10/23 1544 98.9 °F (37.2 °C) Oral 83 136/74 18 95 % RA ? 09/10/23 1212 ? ? 82 ? 20 98 % RA ? 09/10/23 1202 ? ? 78 ? 19 97 % RA ? 09/10/23 1140 ? ? ? ? ? 96 % ? ? 09/10/23 1135 ? ? ? ? ? (!) 83 % ? ? 09/10/23 1130 ? ? ? ? ? 91 % ? ? 09/10/23 0859 98.5 °F (36.9 °C) Oral 75 142/76 18 96 % RA ? 09/10/23 0833 ? ? 78 ? 20 96 % RA ? 09/10/23 0823 ? ? 75 ? 19 95 % RA ? 09/09/23 2349 98.6 °F (37 °C) Oral 73 124/70 20 92 % CPAP 21 % 09/09/23 2326 ? ? 79 ? ? 90 % CPAP 21 % 09/09/23 1948 ? ? 67 ? 19 91 % RA ? 09/09/23 1939 ? ? 86 ? 19 94 % RA ? 09/09/23 1936 ? ? 83 ? 18 94 % RA ?   Physical Exam General appearance - alert, well appearing, and in no distress Mental Status - alert, oriented x 3 Eyes - extraocular eye movements intact, sclera anicteric Nose - normal and patent Throat - normal Chest -dull breath sounds left base, crackles right apex, no work of breathing. No cough. Unable to palpate mass at left chest wall lateral. S/p mastectomy  Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs Abdomen -soft Neurological - motor and sensory grossly normal bilaterally Extremities - no clubbing, cyanosis or edema Skin - warm and dry       Note Details  Author (D.O.) File Time 9/10/2023  5:52 PM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/8/2023  ED to Hosp-Admission (Discharged) on 9/8/2023  ED to Hosp-Admission (Discharged) on 9/8/2023   Routing History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HTN (HYPERTENSION)  ASTHMA, UNSPECIFIED  OBSTRUCTIVE SLEEP APNEA  BRONCHIECTASIS  INTERSTITIAL LUNG DISEASE  FEMALE BREAST INFILTRATING LOBULAR CARCINOMA, LEFT UPPER-OUTER QUADRANT  CANCER METASTATIC TO BONE  COVID-19 PNEUMONIA  ACUTE RESPIRATORY FAILURE  MALIGNANT PLEURAL EFFUSION Care Timeline  09/09   Admitted from ED (Observation) 0314 09/10   Discharged 1913  Discharge   Home or Self Care.   Discharge Instructions (Printed 9/10/2023)   Discharge Orders  MAMMO PROCEDURE  US BREAST PROCEDURE  US BREAST  MAMMOGRAM Medication List at Discharge   albuterol sulfate   2.5 mg /3 mL (0.083 %) Neb soln, Inhale 3 mL via nebulizer every 4 hours as needed for shortness of breath (3 mL is 1 vial)  90 mcg/actuation Hfaa, Inhale 2 puffs by mouth one-half hour before sports or exercise to prevent cough or wheezing. May repeat every 4 hours as needed. 100 days supply is 1 canister. (NOTE: Different manufacturer)  atenolol 12.5 mg Oral DAILY  benzonatate 100 mg Oral 3 TIMES A DAY AS NEEDED  ciclesonide 160 mcg/actuation 1 Puff Inhalation 2 TIMES A DAY, for Asthma prevention and control. Rinse mouth well after use (Note: this replaces QVAR inhaler)  codeine phosphate/guaifenesin 10-100 mg/5 mL 10 mL Oral EVERY 4 HOURS AS NEEDED, . Do not exceed 6 doses in 24 hours  guaifenesin 600 mg Oral EVERY 12 HOURS  hydrochlorothiazide 25 mg Oral DAILY  inhaler, assist devices Use as directed with inhaler  ipratropium bromide 17 mcg/actuation 2 Puffs Inhalation 4 TIMES A DAY, . Shake well before using  naproxen 250 mg Oral 2 TIMES A DAY, . Take with food