Age: 35.0
Sex: M
Vaccine: COVID19
Symptoms: Troponin normal, Urine analysis, Vena cava filter insertion
Clinical narrative: Discharge Provider: MD Primary Care Provider: MD Admission Date: 1/29/2023 Discharge Date: Feb 21, 2023 PRESENTING PROBLEM: DKA, type 1, not at goal [E10.10] Acute hypoxemic respiratory failure [J96.01]   HOSPITAL COURSE: Patient is a 36-year-old man with a past medical history of type 1 diabetes who was in the intensive care unit for management of DKA, acute hypoxic respiratory failure with ARDS secondary to COVID pneumonia and secondary bacterial pneumonia.  He presented from the emergency department with dyspnea and a blood pH of 6.8.  With blood glucose of 600. He was noted to be febrile tachycardic and tachypneic with a leukocytosis.  He was started on EndoTool with mild improvement in DKA prior to transfer.  Subsequently, he developed progressively worsening shortness of breath and was intubated on 01/29.   Initially, he met qualifications for proning given his ARDS diagnosis, however, his respiratory status did improve with deep sedation and paralytic.  For COVID, he received tocilizumab and IV steroids times 10 days.  Notably, family declined remdesivir. He also received antibiotic coverage for CAP, given leukocytosis. During his ICU stay, respiratory status slowly improved, with decreasing needs for ventilator support. He received diuresis due to bilateral pleural effusions. His course was complicated by difficult initially weaning paralytic, then sedation, due to dyssynchrony with the vent.   Course complicated by a right iliofemoral DVT. He was started on heparin. IR was consulted, and did not recommend endovascuaar treatment. Received IVC filter on 2/5.   He was initially on Cefepime for leukocytosis. Sputum positive for stenotrophomonas. ID agreed with transitioning to bactrim.   Despite bactrim, he continue to have an increased leukocytosis and several days of fever.  We had a CT angiogram of the thorax per recommendation by ID. He has also had continued bleeding from the ETT. Heparin was held to see if that would help to stop the bleeding.     A CT angiogram of the thorax was obtained for analysis of the parenchyma, possible bleeding or infection, and bilateral pulmonary emboli were found.  The patient was started on heparin once again, and several labs were obtained including a troponin and BNP which were both normal.  An echo was obtained on the 10th of february as well which demonstrated an ejection fraction of 70% compared to the 52% on the 6th of February.  The left ventricle is hyperdynamic, and the right ventricle has some mild systolic dysfunction.   Pt was extubated on 2/12, and tolerated nasal cannula well.  Patient did have some encephalopathy upon extubation, however this improved.  Patient did not need any pressors during this period. He was transferred out of ICU on 2/14.   Patient was eventually weaned off oxygen, he is now currently on room air.  He completed his course of antibiotics on 02/12 for ventilator associated pneumonia.  He had his Foley catheter removed on 02/16, which tolerated well.  Patient started leukocytosis worsening, he underwent chest x-ray urinalysis CT abdomen pelvis with no clear source of infection.  He was monitored off antibiotics, leukocytosis started to trend down.  He also developed diarrhea, C difficile was negative.  He was started on scheduled Imodium.  His oral intake is improved and now meeting nutritional requirements. Corpak and tube feeding discontinued.