Age: 81.0
Sex: M
Vaccine: COVID19
Symptoms: Bundle branch block left, COVID-19, COVID-19 pneumonia, Capillary nail refill test, Chest X-ray abnormal
Clinical narrative: Hospitalized (5.27.22 - 5.28.22); COVID-19 positive (5.28.22); fully vaccinated PLUS Booster x2 =pfizer x4 d/c summary:    Attestation signed. Was seen, interviewed, and personally examined. All pertinent labs and imaging were reviewed. Management was discussed with the attached provider and I agree with the documented findings and plan of care in their note.  81yo M admitted with COVID pneumonia and hypoxemia. Hypoxemia resolved shortly after admission and symptoms improved. Discharged home on Dexamethasone with plan to follow up with PCP within the next week.  BRIEF OVERVIEW: Discharge Provider:  Primary Care Provider:  Admission Date: 5/27/2022 Discharge Date:  5/28/2022: Active Hospital Problems: Diagnosis Date Noted POA: Pneumonia due to COVID-19 virus 05/28/2022 Yes: Resolved Hospital Problems: Diagnosis- Date Noted- Date Resolved- POA- Acute respiratory failure with hypoxia (HCC) 05/28/2022 05/28/2022 Yes: DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute respiratory failure with hypoxia (HCC) [J96.01]:Pneumonia due to COVID-19 virus [U07.1, J12.82]: HOSPITAL COURSE: 81-year-old male with a past medical history of aortic stenosis status post TAVR 2020, complete heart block with pacemaker, coronary artery disease status post 6 vessel CABG 2009, paroxysmal AFib on Eliquis, dilated cardiomyopathy, type 2 diabetes, OSA, CKD 3B, hypertension who was admitted with COVID no pneumonia and hypoxemia.  He desaturated at home and to 77% and responded well in the emergency department with 2 L nasal cannula saturating in the mid 90s.  He was given a dose of 6 mid Decadron and maintained on oxygen supplementation.  By the morning patient was off of oxygen and saturating in the low to mid 90s.  On ambulation patient desaturated to around 89% but then recovered quickly.  Pulmonary rehab evaluated him and he did not need home oxygen.  At this point given the patient was not requiring supplemental oxygen and had significant clinical improvement he was stable for discharge.  He discharged with 9 additional days of Decadron.  He was told to follow-up with his primary care provider and get a repeat BMP within 1 week. Objective: BP 129/64  | Pulse 56  | Temp 36.7 °C (Oral)  | Resp 18  | Ht 1.905 m  | Wt 100.7 kg  | SpO2 94%  | BMI 27.75 kg/m²  Physical Exam: Vitals reviewed.  Constitutional: General: He is not in acute distress. Appearance: Normal appearance.  HENT:  Head: Normocephalic and atraumatic. Nose: Nose normal. No congestion. Mouth/Throat: Mouth: Mucous membranes are moist. Pharynx: Oropharynx is clear. No oropharyngeal exudate. Eyes:  Extraocular Movements: Extraocular movements intact. Conjunctiva/sclera: Conjunctivae normal. Pupils: Pupils are equal, round, and reactive to light. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses.  Heart sounds: Normal heart sounds. No murmur heard. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Rales present. No wheezing. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. There is no guarding. Musculoskeletal: General: No tenderness. Cervical back: Neck supple. No tenderness. Right lower leg: No edema. Left lower leg: No edema. Skin:General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. H&P:  CHIEF COMPLAINT:   Acute respiratory failure with hypoxia (HCC). ASSESSMENT / PLAN: 81 y.o. male with a past medical history of AS s/p TAVR 2020, complete heart block with pacemaker, CAD s/p 6 vessel CABG 2009, paroxysmal Atrial fib on Eliquis, dilated cardiomyopathy, T2DM, OSA, CKD3b, HTN who presented with cough and hypoxia and was found to be COVID positive. Acute hypoxic respiratory failure COVID. Two weeks upper respiratory infection symptoms with positive COVID test today.  Vaccinated x4. Hypoxic at home to the 70s, hypoxic on arrival today 89% improved with 2 L nasal cannula.  CXR with bilateral patchy opacities. Was prescribed Paxlovid by his PCP and he has taken 1 dose of this. Less likely heart failure, appears euvolemic on exam, and was never short of breath.  Unlikely this is pulmonary embolus, is on Eliquis and no chest pain.  Plan to discuss with him in the morning of starting remdesivir verses continuing his Paxlovid which was started outpatient and brought with him. Although no published clinical trials for inpatient Paxlovid use (only current indication for outpatient to prevent hospitalization and death after positive test), could potentially be as used as an antiviral now as we would remdesivir. As of now however, there are no completed Clinical trials of using Paxlovid in hypoxic patients, or those being treated in the inpatient setting. Anticipate will recommend to not continue taking inpatient. - Oxygen support wean as tolerated - Respiratory isolation - Decadron 6 mg for 10 days started 05/28- no need for additional DVT prophylaxis, is on Eliquis; T2DM   On 48 units Lantus at home.  Last A1c a year ago 7.1; Takes metformin, Jardiance, lixisentide- updated A1c - 24 units to Lantus half home dose- LDC AS; HTN; CAD; CHF; Paroxysmal Afib; Six vessel CABG in 2009, TAVR in 2020 complicated by complete heart block now with dual chamber pacemaker. Last echo EF 52%.  Currently appears euvolemic on exam, not in heart failure exacerbation. Will continue home meds. - Coreg, Lisinopril, HCTZ - Statin (ASA dc'd by EP 01/2022)- Eliquis 5mg BID- OSA   - Home CPAP- CKD3b   To baseline creatinine 1.3.  Creatinine on arrival 1.5. - Daily BMP  BPH- flomax- Code: Full- Diet: Heart healthy 2g/2L- DVT prophylaxis: Eliquis Dispo: Admit to Medicine; HISTORY OF PRESENT ILLNESS: A 81 y.o. male with a past medical history of AS s/p TAVR 2020, complete heart block with pacemaker, CAD s/p 6 vessel CABG 2009, paroxysmal Atrial fib on Eliquis, dilated cardiomyopathy, T2DM, OSA, CKD3b, HTN presenting with hypoxia and cough. Two weeks ago he started developing upper respiratory infection symptoms of cough and congestion.  Cough is mildly productive of green/yellow sputum.  No hemoptysis.  He had a known COVID exposure of his daughter at this time.  He is vaccinated x4 for COVID.  Symptoms did not improve and acutely worsened 2 days ago.  He used his home pulse ox to check his oxygen which she reports was in 70s, and was encouraged by his daughter to present to the ER.  Denies chest pain, dyspnea.  No lower extremity swelling, lightheadedness, palpitations. On arrival to the ED, he was afebrile, slightly hypertensive systolic 150, with O2 saturations 93% on room air.  Remainder of vitals were normal and stable.  Oxygenation increased to 98% with 2 L nasal cannula. Laboratory testing significant for creatinine of 1.57 - baseline around 1.3, mild anemia hemoglobin of 12.0.  Remainder of complete blood count and CMP normal.  COVID testing was positive. EKG normal sinus rhythm showing known left bundle branch block. Chest x-ray shows bilateral patchy airspace opacities worse on the right. He was given a dose of Decadron 6 mg admitted to Medicine. Review of Systems Constitutional:  Negative for chills and fever.  HENT: Positive for congestion. Negative for hearing loss.  Eyes: Negative for visual disturbance.  Respiratory:  Positive for cough. Negative for wheezing and shortness of breath.   Cardiovascular:  Negative for chest pain, palpitations and leg swelling.  Gastrointestinal:  Negative for vomiting, abdominal pain, constipation and blood in stool.  Genitourinary:  Negative for dysuria and hematuria.  Musculoskeletal:  Negative for falls and edema.  Neurological:  Negative for numbness/tingling and weakness.  Skin:  Negative for rash.  OBJECTIVE: BP 134/63  | Pulse 62  | Temp 36.5 °C (Oral)  | Resp 18  | Ht 1.905 m  | Wt 100.7 kg  | SpO2 98%  | BMI 27.75 kg/m²  Physical Exam; Constitutional: General: He is not in acute distress. Appearance: He is not diaphoretic.  HENT: Head: Normocephalic and atraumatic.  Mouth/Throat: Pharynx: Oropharynx is clear. Eyes: Extraocular Movements: Extraocular movements intact.  Cardiovascular:    Rate and Rhythm: Normal rate. Rhythm irregular. Pulses: Normal pulses. Heart sounds: No murmur heard. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: No wheezing. Comments: Diffuse fine crackles bilaterally. Abdominal:    General: Abdomen is flat. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. There is no guarding. Musculoskeletal: Right lower leg: No edema. Left lower leg: No edema. Skin:   General: Skin is warm and dry. Neurological: Mental Status: He is alert.