Office Visit 3/20/2021 Urgent Care  PA-C Family Medicine COVID-19 +1 more Dx Fever  Reason for Visit Progress Notes PA-C (Physician Assistant) ? ? Family Medicine ? ? Encounter Date: 3/20/2021 ? ? Signed Cosigned by: MD at 3/29/2021  9:22 AM Expand AllCollapse All   1. Viral URI  2. Chest congestion      MDM Number of Diagnoses or Management Options Viral URI: new, needed workup Diagnosis management comments: The patient's current medications, allergies, problem list, and family history were reviewed. Please see the physical exam. The patient     See HPI and physical exam to review pertinent information regarding visit. Images available were reviewed by me and reviewed with pt/family. Prescription medication recommendations were reviewed in light of the patient's age, past medical history and comorbidities.Plan of care reviewed; patient agrees with plan. See patient discharge instructions for more details. Follow up with PCP if symptoms do not improve or go to ER if symptoms worsen.   Patient was seen today for fever.   Diagnoses and all orders for this visit:   Viral URI   Chest congestion - POCT COVID-19 Antigen       There are no Patient Instructions on file for this visit.    History  Chief Complaint Patient presents with ? Fever     Fever 101 this morning.chest congstion, body aches, chills since Thursday.     HPI  Patient is a 81 y.o. female presents complaining of chest congestion, cough, body aches and pain in her chest with breathing for the past 2 or 3 days. She denies any loss of taste/smell, sore throat, shortness of breath, vomiting or diarrhea.    ED to Hosp-Admission Discharged  3/22/2021 - 4/18/2021 (27 days) Hospital  MD Last attending ? Treatment team Acute hypoxemic respiratory failure due to COVID-19  Principal problem Discharge Summary MD (Physician) ? ? Internal Medicine         Discharge Summary  Hospitalist Medicine       Date: 4/18/2021 Admission Date: 3/22/2021 PCP: CRNP Length of Stay: 27 Days Discharging provider: MD Discharge Date: 4/18/2021     Admission Diagnosis     Medical Problems     Hospital Problems    POA   * (Principal) Acute hypoxemic respiratory failure due to COVID-19 Yes       Myasthenia gravis without exacerbation Yes       Toxic diffuse goiter without crisis Yes       Long term current use of anticoagulant therapy Not Applicable       Hashimoto's thyroiditis Yes       Persistent atrial fibrillation Yes       Aspiration into airway Yes       COVID-19 Yes       Anemia, normocytic normochromic Unknown  HPI: 81-year-old female with reported myasthenia gravis diagnosed with myasthenia gravis in 2016 noted 5 weeks after finding to have difficulty swallowing and breathing requiring intubation had Plex during admission she was subsequently placed on CellCept and prednisone for long-term but was subsequently weaned off and now follows with neurology Dr., history of thoracic stenosis neck arthritis, Hashimoto's thyroiditis hyperthyroidism on methimazole, heart failure with LVEF of 45%, and atrial fibrillation on Coumadin and rate control agents following with Cardiology who presented to the Hospital on 03/22/2021 with acute hypoxic respiratory failure.  The patient reportedly received her Pfizer first vaccine [per patient's son unclear date-but was reported to be due for her second vaccine at the end of this month] and subsequently was found to have fevers and chills on Saturday for which she went to urgent care and was found to be COVID-19 positive for which she was recommended for Tylenol and supportive care.  On 03/22/2021 it was reported that she was found by EMS to have acute hypoxic respiratory failure with oxygen saturation in the 50s unclear for how long this had occurred for for which patient was emergently intubated.  There was a concern for possible aspiration as as well given unclear how long she was hypoxic for for which she was started on cefepime and vancomycin protocol.  Procalcitonin level was ordered.     Hospital Course:      Please see in details from H&P initially from critical care since patient was being they are almost 22 days. There is multiple consult including cardiologist palliative care note as well as urologist consult note   In briefly this is a very pleasant 81-year-old female she had a history of myasthenia gravis currently treated with Dr. not in medication now for myasthenia gravis chronic atrial fibrillation long-term use of anticoagulation Coumadin history of toxic goiter currently on methimazole she was admitted initially on March 22 because she was having chills fever shortness of breath and EMS found that she is having acute hypoxic respiratory failure oxygen saturation is only 50% and emergently intubated admitted in critical care unit. Patient was intubated on March 22 meanwhile patient has a complicated series whilst she was in ICU. She was treated twice for septic shock she was treated first Covid pneumonia respiratory failure with possible aspiration. She was unable to extubate almost 19 days. Eventually she was extubated on 1 April 9. After that patient initially on BiPAP and then she tolerated nasal cannula successfully currently 3 L of oxygen. Meanwhile because of sepsis aspiration pneumonia COVID-19 pneumonia respiratory failure patient was treated with and also urinary tract infection patient was treated with multiple antibiotic vancomycin and Maxipime. For COVID-19 pneumonia she also was treated for tract residual normal. And also Decadron. Patient was not a candidate for remdesivir at that point. After extubation patient, up very slowly patient was transferred to PCU because of tachycardia and hypotension unable to thread beta-blocker digoxin and Cardizem the medication was adjusted pretty slowly patient was started Lovenox injection for bridging Coumadin Coumadin was initially hold been longtime and then after Lovenox injection and Coumadin was started patient currently INR is 1.9 today. She was Coumadin been longtime because her Chad vascular score was high she also had a history of congestive heart failure in addition of chronic atrial fibrillation heart rate is fluctuated in the range of 80-120. She is currently on digoxin we will continue digoxin she is currently on Toprol which started 50 mg and currently 100 mg Toprol she also have a Cardizem with splitting the medication 120 mg p.o. twice daily. Heart rate is better controlled today blood pressure is low borderline this patient need to be watched even in the nursing home for further evaluation of medication adjustment. She also mentioned that she is having chronic hypokalemia potassium was replaced alert here and so then started potassium 20 M EQ p.o. twice daily may need to further adjustment and follow-up potassium in the nursing she she was tachycardic heart rate in module was started recently as 7 days ago now her heart rate is much better now this patient need to see endocrinologist also to follow-up.   Patient was complicated with urinary retention and continue straight cath and finally ended up with Foley's catheter this patient must need to evaluate by urology for further evaluation of chronic urinary retention. Meanwhile patient clinically stable vitals are good she does not have any fever shortness of breath tolerable with 3 L of oxygen now she does not have any chest pain she is not in any myasthenia gravis medication this patient will benefit to see follow-up with pulmonary group for post Covid pneumonia require long-term intubation and also neurology for myasthenia gravis Dr. This patient will benefit to a urologist outpatient and also physician to nursing home need to adjust medication in the setting of hypotension tachycardia we will continue Coumadin current dose 7.5 mg and may need to further adjustment slowly. She is currently on 3 L of oxygen we will continue and titrate down slowly.     Discharge disposition is nursing home Condition upon discharge patient is awake alert oriented no chest pain still 3 L of oxygen tolerable.