Received Mar 31, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 3 | 069H22A | UN / UN |
Name: Medical Record #: Age: 66 y.o. DOB: 4/XX/1958 Admit date: 3/24/2025 Discharge date: 3/25/25 Admitting Physician: DO Attending Physician at the Time of Discharge: DO Primary Care Physician: NP Reason for Admission: Acute hypoxic respiratory failure Brief Summary of Hospital Stay: Patient is a 66 y.o. female with a history of COPD (last PFTs 2014), HFpEF, HTN, hx CVA, and tobacco use disorder who presented to ED on 3/24/25 due to 2 weeks of productive (clear sputum) cough, SOB, sore throat, rhinorrhea, nasal congestion as well as right lower back pain. In the ED, she tested positive for COVID-19 and was admitted for acute hypoxic respiratory failure secondary to COVID-19 (SpO2 improved to mid-90s on 2 L nasal cannula) and COPD exacerbation. CXR was largely unremarkable. CT thorax taken due to right back/flank pain showed cholelithiasis, cirrhosis, and bilateral kidney lesions/scarring. Superimposed bacterial infection less likely due to low procal 0.07, WBC wnl. She was also found to be in hypertensive urgency secondary to medication non-compliance as she reported not taking her anti-hypertensive meds for the past 2 weeks. Home blood pressure medication including Norvasc, lisinopril, and hydrochlorothiazide were restarted and labetalol was provided as needed during admission. By this morning, she was breathing comfortably on room air and endorsed improvement in her cough, work of breathing, and appetite. Right lower back pain is most likely musculoskeletal in nature. Discharge to home in stable condition on 3/25/25. Acute hypoxic respiratory failure, resolved Moderate persistent asthma/COPD exacerbated by COVD-19 - Continue prednisone 40mg for 4d - Continue supportive care with Mucinex, Tylenol - Continue: albuterol as needed for rescue - START: Symbicort bid for maintenance - Outpatient: pulmonary referral Discharged to Home