Reporte zur Charge 32030ND

Symptomtext

63 y.o. female with a history of asthma and COPD who presents to the emergency department via EMS for evaluation of a breathing problem. The patient reports that a few days ago she developed a cough, rhinorrhea, loss of smell, and right-sided chest pain that has been constant since onset but worsens with coughing. The patient has been using her Albuterol inhaler with no improvement. The patient is on 3 L of supplemental O2 at baseline and has had to increase this with onset of her symptoms, and she has still had difficulty breathing, so she decided to come to the ED. Here, the patient denies vomiting, diarrhea, fever. Of note, the patient is vaccinated for COVID. She is not currently on steroids. Albuterol inhaler did not improve and she increased her oxygen to 4 L/min without improvement in her breathing. Patient was found to have COVID 19 as well as CAP 2/2 strep pneumonae. Patient treated with abx, steroids and improved to her baseline 3-4L NC. She was discharged with refills of her medications and will complete a 7 day course of abx for her CAP. COVID-19 pneumonia COPD exacerbation Chronic hypoxic respiratory failure CAP 2/2 strep pneumonae -Patient states that she is on 3-4 L/min of oxygen via nasal cannula at baseline -She presented with shortness of breath, worsening cough -Likely COPD exacerbation in the setting of COVID-19 pneumonia -Patient started on 6 mg IV Decadron on 1/6. Further steroids were discontinued at that time as she appeared to be on her baseline oxygen requirements. However, with worsening cough, shortness of breath. Patient started on IV Solu-Medrol 80 mg BID on 1/8. -PTA aclidinium bromide BID, Symbicort BID--refilled at d/c -Sputum cx from 1/8 growing strep pneumonae-- given ceftriaxone changed to ceftin at d/c -she was at her baseline 02 requirement at discharge -cleared by PT to return to prior living situation. Hypertension: Blood pressures stable -Continue PTA clonidine and amlodipine Tachycardia-resolved Intermittent right-sided chest pain -Could be related to shortness of breath, coughing. Concern for mild withdrawal from methadone and presentation. -Continue Tylenol PRN -Continue PO Oxycodone 5 mg q8h prn Chronic pain Hx opioid use disorder, on methadone Well controlled on methadone 90 mg daily. Patient stated that she did not take methadone for 2 days due to shortness of breath -Continue PTA methadone Major depressive disorder: Continue PTA Paxil Anxiety: Continue PTA Buspar