Age: 74.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Tachycardia, Troponin normal, Ultrasound Doppler abnormal, Wheezing
Clinical narrative: J&J Dose 8/17/21 (201A21A) COVID Positive 2/17/22  2/17/22: Patient is 75-year-old male with past medical history of psoriasis on monthly Cosentyx injection, hypertension, dyslipidemia, tobacco abuse.  He is being transferred from ED for management of acute hypoxic respiratory failure secondary to COVID-19 pneumonia and bilateral pulmonary embolism with signs of right heart strain.  He presented emergency room with a complaint of shortness of breath.  Patient was in relatively good state of health until 4 days ago when he started to have progressively worsening dyspnea worse with exertion.  He also reported cough productive of yellowish sputum since 2 days ago.  He reported right-sided chest heaviness.  No palpitations fever chills or rigors. Patient denied any sick contact in the recent past.  He was diagnosed with COVID-19 infection 2 years ago but did not require any hospitalization.  Patient reported receiving Johnson Johnson COVID-19 vaccine a year ago.  Did receive any booster dose.  Patient reported poor appetite.  No report of nausea vomiting or diarrhea.  Patient denied use of tobacco products.  He admits drinking up to half a pt of vodka at twice a week.  No history of alcohol withdrawal. His last drink was 12 days ago.  Patient takes monthly Cosentyx injection for psoriasis.  His last injection  Upon evaluation at the emergency room, he was afebrile. He was hypoxic with oxygen saturation 86% on room air.  He was tachycardic.  Significant lab findings are creatinine of 1.31 which is close to his baseline and mild transaminitis. He was also noted to have lactic acidosis at 6.1 and proBNP of 1279. Lactic acid trended down to 2.6 after IV hydration.  CBC revealed leukocytosis at 19,000 with slight left shift.  D-dimer was significantly elevated more than 35. CT chest with IV contrast was obtained which revealed right-sided pulmonary thromboembolism involving right middle, lower and lower lobes with some signs of right heart strain.  However troponin was negative.  CT chills also revealed patchy multifocal bilateral infiltrates suggestive of viral pneumonitis. Nasopharyngeal swab was positive for COVID-19.  At the referring facility ED, patient was started with IV heparin drip.  He also received IV Solu-Medrol, DuoNeb nebulization and ceftriaxone IV.  3/2/22: The patient presented to the hospital with shortness of breath and fever and cough, he was hypoxic and require initially BiPAP, had bilateral wheezing, his COVID-19 test is positive, he received 1 dose of the COVID vaccine, the patient had elevated inflammatory markers and elevated D-dimer, CT chest angiogram show bilateral multiple pulmonary embolism initially worrisome for submassive PE with RV strain, the patient placed on heparin drip and the cardiologist consulted and the patient had echocardiogram show EF 60% without signs of RV strain, the cardiologist recommend on anticoagulation and no intervention, the patient admitted to the ICU and he require to be on noninvasive ventilator BiPAP and OptiFlow, he received Decadron and remdesivir and antibiotics for possible secondary bacterial pneumonia, he was not candidate for Actemra because he was on immunosuppressive therapy for history assess, patient has history of alcoholism but he did not develop any signs of alcohol withdrawal, history of hypertension dyslipidemia and were controlled.  The patient does have lower limbs Doppler ultrasound show asymptomatic popliteal aneurysm and no DVTs.  We have been able to taper the patient off oxygen gradually, and oxygen walking test done before the patient discharged and show the patient does not require oxygenation at rest and required 2 L of oxygen with activities.  Discussed with the patient, will discharge the patient home with home oxygen and VNA, follow-up with pulmonologist in 5 weeks and continue tapered steroids.