Received Mar 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 4 | GH9702 | UN / UN |
Discharge Summary MD (Physician) ? General Medicine BRIEF OVERVIEW: Admission Date: 2/21/2025 Discharge Date: 2/27/2025 Discharge Disposition: Home without services Active Issues Requiring Follow-up: COPD DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Mixed metabolic and respiratory acidosis of newborn [P84] Pneumonia due to infectious organism, unspecified laterality, unspecified part of lung [J18.9] Acute on chronic hypoxic respiratory failure [J96.21] Acute on chronic respiratory failure [J96.20] HOSPITAL COURSE: 64 y.o. female with a history of COPD on 1.5-2 L nasal cannula at baseline, OSA, morbid obesity, and Crohn's disease who presented for increased shortness of breath and dyspnea. Acute on chronic hypoxic respiratory failure - resolved COPD Exacerbation - improving Leukocytosis Recent COVID-19 infection - On Chronic 1.5-2L of O2 at home but now requiring HFNC. O2 supplementation PRN w/ goal O2 saturation 88-92% - CT chest notable for extensive multifocal airspace disease - Remdesivir - Levaquin, metronidazole, vancomycin - Oral dexamethasone - Symbicort - Continued home montelukast - Albuterol PRN - Supportive care Hypertension - Continue home amlodipine - Home losartan increased from 25 to 50 mg; continue Hyperglycemia in the setting of steroid use Type II Diabetes, not on long term insulin - HbA1c 7.2 - Held home oral diabetic medications - Lantus 34U - Basal bolus insulin - Carb Control Diet History of CVA - Continued ASA, statin GAD - Continued BuSpar - Held trazodone - PRN Atarax Chronic low back pain Glaucoma - Continued eye drops Hyponatremia, mild - stable Hypocalcemia - resolved - Checked ionized calcium - Checked vitamin D History of Crohns Does not appear to be on immunomodulating therapy - Continued Bentyl Vertigo - PRN meclizine Microcytic anemia Morbid obesity CONSULTS / RECOMMENDATION: IP CONSULT TO NUTRITION Discharged to Home.