Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin decreased, Hypoxia, Lung infiltration, Malaise, Mental impairment
Clinical narrative: COVID Vaccine Breakthrough Case  Pfizer Dose 1 1/22/21 Pfizer Dose 2 2/12/21 COVID Positive 8/30/21  History of Present Illness  9/13/21: 69-year-old male with pmh of HTN, diabetes, CKD stage 3, HLD, mental disability, BPH, LE edema, and obesity is being admitted for hypoxia w/ O2 at 89-90% in the setting of COVID (+). Presented to the ED today with SOB and nonproductive cough, positive COVID test on 8/30. Symptoms started on 8/30 along with a temp of 101.6 brought down with Tylenol.  No subjective fevers, chills, chest pain, dizziness, abd pain, diarrhea, headaches, or weakness.  He was due for an infusion today, but unable to complete due to hypoxia.   He lives at a Center where there has been many residents COVID positive.   ED course:  Patient had a temperature of 100.1°.  Oxygen at 91% on room air, otherwise stable.  Lab significant for Stable kidney function with BUN of 29 and creatinine of 2.24. CXR showed patchy infiltrate most pronounced in the left lower lung suspicious for pneumonia.  Cardiomegaly. Right-sided aortic arch.  Blood cultures sent.  Patient given 1 L NS.   Patient currently complaining of only nonproductive cough, denies shortness of breath.  Has no questions or concerns at this time.   Family history:  Reviewed  Social history:  No tobacco use, no marijuana use, no alcohol use, no illicit drug use  Surgical history:  Reviewed Allergies:  Hydralazine (vomiting)  Vaccines:  2 doses of Pfizer COVID vaccine, 2nd dose received in 2/2021  Review of Systems    Negative apart from HPI.  Physical Exam Vitals & Measurements T: 100.1  °F   HR: 76(Peripheral)  HR: 76(Monitored)  RR: 26  BP: 136/61  SpO2: 93%  HT: 165.1 cm  WT: 106.818 kg     Gen: Nontoxic, well appearing, no acute distress.  Head: Normocephalic.  CV: RRR without murmurs.  +1 LE edema.  Lungs: Mild respiratory distress, expiratory wheezing and rales present bilaterally, worse on the left  GI: Soft, nondistended, nontender. Bowel sounds present. No guarding, rebound.  Reducible nontender umbilical hernia Neuro:  Alert and oriented.  Skin: Warm, dry, intact.  Psych:  Cooperative.  Mental impairment. Appropriate mood and affect.  Assessment/Plan     Hypoxia secondary to left-sided pneumonia, positive COVID  -Nonproductive cough started 8/30, positive COVID test w/ known sick contacts  -CXR left lower lung infiltrate suspicious for pneumonia, BC X2 pending  -Labs ordered:  CK, D-dimer, CRP quantitative, LVH, troponin  -RT to evaluate and treat, oxygen prn, continuous pulse. PT and OT consulted.  -Per COVID protocol: Dexamethasone 6 mg IV daily, start remdesivir 200 mg IV OTO, 100 mg IV daily for 4 days thereafter  -Enoxaparin 40 mg daily indicated due to CrCl >30, but due to low platelet count of 80 not given  Hypertension  -Continue home dose amlodipine 10 mg, lisinopril 30 mg, metoprolol succinate 100 mg daily  Type II Diabetes  -Mild correction scale, diabetic diet, Accu-Cheks ACHS  -may consider lantus based on admission day need  HLD  -Continue home dose rosuvastatin 40 HS  CKD Stage 3  -Cr near baseline at 2.24 on admission, will continue to monitor  -patient follows w/ Dr.  Obesity  -Will encourage weight loss with diet and exercise  Lower extremity edema  -Secondary to venous insufficiency  -recommend elevation  BPH  -No longer on tamsulosin, asymptomatic  Fluids: PO Electrolytes: replace PRN Nutrition: Diabetic diet GI Prophylaxis: None DVT Prophylaxis: SCDs Code Status: Full  Disposition: Managing hypoxia with steroids and prn oxygen, RT to eval and treat. COVID treatment protocol initiated - no Enoxaparin 2/2 low platelet count. Labs pending.     Discharge Diagnosis Hypoxia secondary to COVID pneumonia, HTN, type 2 diabetes, HLD, CKD stage 3, obesity, lower extremity edema, BPH, hyponatremia, elevated LDH, elevated d-dimer, elevated CRP, thrombocytopenia  Hospital Course  Patient is a 69 yo male with pmh of HTN, diabetes, CKD stage 3, HLD, mental disability, BPH, LE edema, and obesity admitted to our care for hypoxia 2/2 COVID pneumonia.  He lives at a HCF, where there are many positive COVID patients.  ED course:  Febrile at 100.1°, O2 at 91% on room air, otherwise stable.  Pertinent labs: COVID +, baseline BUN of 29, Cr 2.24, and platelet count of 87. CXR showed patchy infiltrate most pronounced in the left lower lung suspicious for pneumonia. Pt given 1 L NS. BC drawn and showed NGTD.   COVID protocol was initiated and subsequent labs showed D-dimer 1.23, CRP 14.6, LDH 289. Pt received the following medications per the protocol: 10 days of dexamethasone 6 mg IV, 5 day course of remdesivir, 5 day course of ceftriaxone and azithromycin, and 8 days of Lovenox 40 mg daily. Patient's oxygen requirements started at 2 L, and increased to 11 L on 09/07.  From then on, oxygen requirements slowly decreased and patient was weaned down to 4 L.  Home O2 test performed 9/13 showed patient requiring 4 L oxygen while ambulating.   D-dimer on 09/07 decreased 0.99 but then subsequently increased to 1.69 on 09/10 and 1.87 on 09/13.  However, due hemodynamic stability, overall improvement of oxygen status, and current therapeutic dose of Lovenox, PE was of low indication and patient was monitored.  CRP continued to trend down. Patient continued to deny fevers, chills, shortness of breath or headaches.  His only complaint was mild nonproductive cough that he has had over the entire summer.   Patient's sugars were uncontrolled during hospitalization, likely due to steroid administration.  Last A1c at home was 6.  Insulin was added to regimen and included 10 units of Lantus HS, moderate correction scale, and increasing requirements previous insulin.  These were stopped on the day of discharge due to discontinuation of steroids.  Physical Exam Vitals & Measurements T: Warm(Skin)  TMIN: 36.3  °C (Tympanic)  TMAX: 98.1  °F HR: 74(Peripheral)  RR: 18  BP: 120/66  SpO2: 90%     Gen: Nontoxic, well appearing, no acute distress.  Head: Normocephalic.  CV: RRR without murmurs.  No peripheral edema.  Lungs  Clear to auscultation bilaterally without rales, rhonchi, or wheezes.  No respiratory distress.  GI: Soft, nondistended, nontender. Bowel sounds present. No guarding, rebound, or masses.  Neuro:  Alert and oriented.  No focal neurologic deficits. Speech clear.  Skin: Warm, dry, intact.  Psych:  Cooperative.  Labs (Last four charted values) WBC      H 12.27   (SEP 13)   10.35   (SEP 12)   10.20 (SEP 11)   8.36   (SEP 10) Hgb      L 13.7   (SEP 13)   14.1   (SEP 12)   L 13.3 (SEP 11)   L 12.7   (SEP 10) Hct      44.2   (SEP 13)   45.7   (SEP 12)   42.0    (SEP 11)   L 40.3   (SEP 10) Plt      264   (SEP 13)   243   (SEP 12)   224    (SEP 11) 170   (SEP 10)  Na      138   (SEP 13)   141   (SEP 12)   137    (SEP 11) 135   (SEP 10) K      4.8   (SEP 13)   4.6   (SEP 12)   4.6    (SEP 11) 4.7   (SEP 10) CO2      28   (SEP 13)   29   (SEP 12)   26    (SEP 11) 26 (SEP 10) Cl      101   (SEP 13)   103   (SEP 12)   102    (SEP 11) 102   (SEP 10) Cr      H 1.89   (SEP 13)   H 1.88   (SEP 12)   H 1.78 (SEP 11)   H 1.90   (SEP 10) BUN      H 44   (SEP 13)   H 43   (SEP 12)   H 45   (SEP 11)   H 47   (SEP 10) Glucose Random        H 139   (SEP 13)   H 135  (SEP 12) H 149   (SEP 11)   H 167   (SEP 10) Ca      L 8.4   (SEP 13)   L 8.4   (SEP 12)   L 8.1   (SEP 11)   L 8.1   (SEP 10)  D-dimer: 1.87 CRP: 0.3   Home Medications (12) Active  acetaminophen 325 mg oral tablet See Instructions  amLODIPine 10 mg oral tablet See Instructions  Aquaphilic with Urea 10% ointment 1 applicatorful, Topical, Daily (Once Daily)  Glucometer See Instructions  Lancets See Instructions  lisinopril 30 mg oral tablet See Instructions  metoprolol succinate 100 mg oral tablet, ER 100 mg = 1 Tab, PO, Daily (Once Daily)  Orthopedic Shoes See Instructions  rosuvastatin 40 mg oral tablet See Instructions  sitagliptin 25 mg oral tablet 25 mg = 1 Tab, PO, Daily (Once Daily)  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Cap, PO, Daily (Once Daily)  Test strips See Instructions  Discharge Plan Pt going home on 4 L O2 and the same medications as were present on admission. Per COVID protocol, VTE risk is 1, so Lovenox was not continued after hospitalization.  f/u PCP       Patient Discharge Condition Requiring 4 L O2 to ambulate, but otherwise stable.  Discharge Disposition  Center     Follow-Up       With  When  Contact Information         Additional Instructions: 4L NC continuous. Please call  when you arrive home for your equipment to be delivered. Call same number for any questions or concerns.        Center Additional Instructions: D/C to HCF             Additional Instructions: Monitor O2 needs and wean down as appropriate.       Signature Line  Electronically Signed By:MD   Addendum by DO, on September 13, 2021 15:22:40  (Verified)    Supervision addendum:  I have interviewed and examined the patient. I have discussed their management and plan of care with the resident. I have reviewed the resident's notes and orders and agree with documented findings and plan of care.     Signature Line  Electronically Signed By:DO, On 09.13.2021 03:23 PM  Electronically Signed By: DO, On 09.13.2021 03:23 PM   Addendum by DO, on September 14, 2021 13:33:01 (Verified)    I have interviewed and examined the patient and discussed the management with the resident. I have reviewed the note and orders and agree with the plan of care.   he is feeling better and ready to go home.  spoke with staff from HCF and able to accomodate up to 4l of oxygen, which he's on.  lungs clear.  heart is regular. will dc with 4l of oxygen.  plan to check pulse ox daily and as needed.  any sat greater than 87% is acceptable at this time.