Age: 76.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: International normalised ratio increased, Joint swelling, Lactic acidosis, Nitrite urine absent, Procalcitonin increased
Clinical narrative: Hospitalized;  COVID-19 positive (9.5.21);  fully vaccinated  Admission Date: 9/4/2021 Discharge Date:  09/13/2021 ASSESSMENT / PLAN: 1. COVID-19 pneumonia, Tylenol p.r.n. fever, oxygen as per protocol, IV remdesivir, Decadron, bronchodilators, zinc, thiamine, undo with full inflammatory markers 2. Atrial fibrillation monitor telemetry, continue metoprolol, and Coumadin for anticoagulation.  INR is therapeutic at 2.3 3. Possible sepsis likely from COVID-19 lactic acidosis resolved, procalcitonin elevated, CRP also elevated, urinalysis negative nitrite and esterase , continue ceftriaxone and Zithromax for possible superimposed bacterial pneumonia 4. DVT prophylaxis patient therapeutic on Coumadin.  Pharmacy to dose Coumadin HISTORY OF PRESENT ILLNESS: PT is a 76 y.o. male with history of chronic knee pain who had initially come to the emergency room for evaluation of the he lost balance while coming out of his truck and fell backwards.  He claims he did not hit his head and he did not lose consciousness but reported worsening right knee pain.  He also reports occasional cough which sometimes is productive none mild shortness of breath, he does not use oxygen at home.  He denies chest pain reports fever denies nausea vomiting abdominal pain or diarrhea.  Denies dysuria hematuria no leg pain or swelling In the emergency room maximum temperature was 38.5° centigrade, patient was hypoxic with oxygen saturation of 87 and was subsequently placed on 2 L nasal cannula, troponin less than 6, lactic acid was 2.3 but trended downwards, procalcitonin 1.64, WBC count of 11.65 2 CT scan of the head was unremarkable CTA of the chest no evidence of PE shows mild COVID-19 pneumonia PRESENTING PROBLEM: Weakness [R53.1] Atrial fibrillation with RVR (HCC) [I48.91] Fever, unspecified fever cause [R50.9] Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present (HCC) [A41.9] Pneumonia due to 2019 novel coronavirus [U07.1, J12.82] COVID-19 virus infection [U07.1] HOSPITAL COURSE:  Admitted to the hospital with COVID pneumonia, treated with steroids, remdesivir, supplemental oxygen, empirical antibiotic coverage.  Blood culture grew Streptococcus agalactiae, initially source was thought to be the right knee, it was initially swollen and painful following a fall that the patient experienced prior to coming to the hospital.  Orthopedics were consulted, aspirate negative for Streptococcus agalactiae. Treatment with Rocephin 2 g daily that the ID consultant recommended be continued for 2 weeks, it started on the 7th, it will be continued until the 20th on outpatient basis. Oxygen was weaned down to room air fairly early during the course of hospitalization The patient is on Coumadin for history of atrial fibrillation, initially INR was supratherapeutic, over the last 3 days before today INR has been subtherapeutic therefore a CT angiography of chest to rule out PE given the fact that the D-dimer was more elevated was done, negative for PE but more inflammatory changes of COVID found. For the AFib RVR in addition to his Lopressor 100 mg twice a day I added Cardizem initially IV and subsequently orally, I added digoxin up to 125 mcg daily but previous to that loading of 2 consecutive days 500 mcg IV daily done.  Since heart rate was still elevated I increased the Lopressor to 150 mg by mouth twice a day.  I explained to the patient that this is more than likely consistent with AFib RVR resulting directly from the presence of COVID pneumonia therefore I am anticipating that in the future these medications will need to be scaled back so I encouraged him to follow-up with his primary care physician to do that. Need for continuous hospitalization up to this point was 1. COVID pneumonia isolation, 2. Need for IV antibiotic, 3. Ongoing AFib RVR with rates above 100 requiring active medication adjustment and intravenous medication and close monitoring.