H & P note 2

Admission History and Physical

ANP 652: Robin McLinn

Patient Name: A.S. DOB: 03/15/1992

Provider: ACNP Student Robin McLinn RM#: ED #14

ADM: 07/14/2020 Patient Type: Tele Inpatient

CHIEF COMPLAINT: Chief Complaint: “I have had a fever for 3 days with diarrhea starting today, I feel really tired and can’t catch my breath. I had a COVID 19 test come back positive from an outside lab”

RELIABILITY: History obtained from the patient, and EMR.

HISTORY OF PRESENT ILLNESS: This is a 28-year-old Hispanic male that was brought to the ED by his girlfriend. Patient has had a 3+ day stated fever accompanied by diarrhea and shortness of breath. Patient was at a family party a three weeks ago, where he later learned an aunt had tested positive for COVID-19. Patient started having a cough so decided to get tested by an outside lab 7 days ago. Stated he was informed he was positive yesterday. Patient has been mildly symptomatic with a cough up until 3 days ago where he began having chills and became febrile. He now reports diarrhea x2 today, difficulty breathing, and productive cough. He is currently in the ED. Girlfriend is retrieving testing confirmation from apartment. FULL CODE

PAST MEDICAL HISTORY: Obesity, chicken pox (4yrs old), broken leg 2010, depression treated by PCP.

PAST SURGICAL HISTORY: Appendectomy 2016, Tonsillectomy/Adenoidectomy approximately 23yrs ago.

SOCIAL HISTORY: Single. Lives in apartment with girlfriend. Denies tobacco, illicit drugs, or vaping. Drinks socially 4-5 drinks/month. Employed at Amazon full time.

FAMILY HISTORY: Father has HTN, DMII, obesity. Mother had breast cancer 2015 both alive in their late 50’s. Two brothers in good health, no children.

( 1 )

( This study source was downloaded by 100000800518114 from CourseHero.com on 12-15-2021 07:43:31 GMT -06:00 ) ( https://www.coursehero.com/file/65712889/H-and-P-2docx/ )

MEDICATIONS: Celexa dose unknown daily for depression. Melatonin 5mg as needed for sleep at night.

ALLERGIES: Seasonal, shellfish

REVIEW OF SYSTEMS:

CONSTITUTIONAL: SOB, chills, febrile, HEAD AND NECK: Reports headache

CARDIOVASCULAR: denies chest pain or palpitation, reports diaphoresis RESPIRATORY: Reports difficulty breathing, productive cough, denies hemopytosis GASTROINTNTESTINAL: Reports diarrhea x 2, denies blood in stools, reports nausea GENTINOURINARY: Denies urgency, denies foul odor

MUSCULOSKELETAL: Reports joint and muscle pain NEUROLOGIC: Reports weakness, Denies syncope, dizziness PSYCHOLOGIC: Reports depression IMMUNOLOGIC/ALLERGY: Denies bruising or bleeding INTEGUMENT: Denies skin changes or rash

PHYSICAL EXAMINATION:

VITAL SIGNS: T: 38.1 C oral, BP: 159/79, P: 107, RR: 28, PO: 90 on 7L Pain 2

GENERAL: Normal appearance, obese, nontoxic appearance, otherwise healthy

HEENT: no JVD, Normocephalic, trachea midline, PERRLA, mucous membranes moist and pink, sclera white.

NECK: No masses, no nodules, no trachea deviation

CHEST: AP Diameter 2:1, Lung sounds have crackles, asymmetrical vocal resonance, abnormal breath sounds.

HEART: S1 S2, no murmers, no heaves, EKG 12 lead Sinus tachycardia at 107 bpm ABDOMEN: Soft, denies tenderness, bowel sounds present

NEUROLOGIC: Alert and oriented x 3, PERRLA, answers questions appropriately EXTREMITIES: Palpable pulses, no wounds or lesions, no edema

GENERAL: alert and oriented x 3

DIAGNOSITIC EVALUATION:

Chest X-Ray: Bilateral alveolar opacities with ground glass appearance. Ground glass opacities are consistent with COVID-19 (Jacobi, Chung, Bernheim, & Eber, 2020).

LABS: 07/14/2020

CRP: 33.1 mg/L 1.0 mg/L and 3.0 mg/L

ALT: 57

AST: 62

WBC 14.0

LYM: 1.20

Albumin: 1.9

Urea: 0.835

Bicarbonate: 25 mEq/L

Ferritin: 340.3

PCO2: 51.0 FiO2: 30% P/F Ratio: 170 mmHg

ASSESSMENT:

1. Hypoxia (R09.02): Patient presented to the ER with a complaint of shortness of breath which is still present. Patient is on 5 Liters of oxygen via nasal cannula. This may be a result of COVID-19 or Pneumonia.

2. Shortness of Breath (R06.02): Related to hypoxemia

3. Fever, unspecified (R50.09): Patient has reported a fever over the last few days, was controlling with acetaminophen prior to arriving at ER.

4. Tachycardia, unspecified (R00.0): Can be a normal response to fever

5. Cough (R05): Inflammation and fluid in the alveoli will produce a cough, likely from COVID-19 or pneumonia

6. History of depression (Z86.59): Controlled by PCP with Celexa, denies depression at this time.

7. Obesity, unspecified (E66.9): Patient has a history of obesity

DIFFERENTIAL DIAGNOSIS:

1. COVID-19 (U07.1): This patient has a reported positive COVID-19 test from an outside lab, new test being run to confirm a diagnosis. COVID-19 has quickly become a global pandemic infecting 5.8 million people globally (Michienzi, & Badowski, 2020).

Symptoms are fever, chills, SOB, headache, nausea or vomiting, and diarrhea to name a few.

2. Pneumonia (J12.89): Possible co-infection. COVID-19 and pneumonia have similar symptoms. Pneumonia can be both viral or bacterial which cannot be predicted without testing (Lhommet, Garot, Grammatico-Guillon, Jourdannaud, Asfar, Faisy,... & Lanotte, 2020).

3. Coccidioidomycosis (B38.9) Unlikely, however symptoms are similar with fever, shortness of breath, headache, and fatigue (Sarkisyan, 2019).

Plan:

1. Admit to observation unit with continuous cardiac monitoring

2. Regular diet as tolerated

3. Monitor O2 saturation, titrate as needed, report changes

4. Pulmonology consult

5. Start COVID-19 protocol (IV Ascorbic acid, Zinc gluconate, dexamethasone)

6. Treat with broad spectrum antibiotic until Pneumonia ruled out.

7. Celexa 10 mg daily (home medication)

Additional labs ordered:

Type and Screen- For Possible Infusion Convalescent Plasma Legionella urine- R/O pneumonia

Strep pneumonia urine- R/O pneumonia Sputum Culture- R/O pneumonia

Cocci IgG- R/O coccidioidomycosis Cocci IgM- R/O coccidioidomycosis D-dimer

Geriatric Specific

COVID-19 has quickly become a global pandemic infecting 5.8 million people globally (Michienzi, & Badowski, 2020). There is a heightened risk to the elderly with regards to COVID-19 due to their weakened immune system. The CDC reports 8 out of 10 COVID-19

deaths are in adults 65 years and older (CDC, 2020). There is a generally a higher risk for a severe illness in patients over the age of 50 which climbs up to severe illness in patients 85 and older who contract COVID-19 (CDC, 2020). The public is reminded daily to limit interactions with people, wear a mask, and stay home as much as possible, clean and disinfect surfaces, and wash hands often, to protect against COVID-19.

There are a variety of abnormalities found in the labs of patients who test positive for COVID-19. Current studies have found a positive result on the impact of ascorbic acid and zinc gluconate and dexamethasone, in reducing the symptoms in patients diagnosed with COVID-19 (NIH, 2020). Studies are also showing Remdesivir, a broad spectrum anti-viral drug to have good results in decreasing the duration of COVID-19.

References

Centers for Disease Control and Prevention, (2020). Older adult’s coronavirus disease.

Retrieved from https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-

precautions/older-adults.html

Jacobi, A., Chung, M., Bernheim, A., & Eber, C. (2020). Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Clinical imaging, 64, 35–42. https://doi.org/10.1016/j.clinimag.2020.04.001

Lhommet, C., Garot, D., Grammatico-Guillon, L., Jourdannaud, C., Asfar, P., Faisy, C., ... & Lanotte, P. (2020). Predicting the microbial cause of community-acquired pneumonia: can physicians or a data-driven method differentiate viral from bacterial pneumonia at patient presentation?. BMC pulmonary medicine, 20(1), 1-9.

Michienzi, S. M., & Badowski, M. E. (2020). Can vitamins and/or supplements provide hope against coronavirus?. Drugs in Context, 9.

Sarkisyan, D. (2019). Acute Pulmonary Coccidioidomycosis. Proceedings of UCLA Health, 23.

U.S. National Library of Medicine, (2020). Coronavirus 2019(COVID-19) Using ascorbic acid and zinc supplementation. Retrieved from https://clinicaltrials.gov/ct2/show/NCT04342728

Wilkerson, R. G., Adler, J. D., Shah, N. G., & Brown, R. (2020). Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19. The American journal of emergency medicine, S0735-6757(20)30390-9. Advance online publication. https://doi.org/10.1016/j.ajem.2020.05.044