Age: 59.0
Sex: M
Vaccine: COVID19-2, FLUC4, PPV, VARZOS
Symptoms: Lung infiltration, Malaise, Nicotine dependence, Pneumonia, Pneumonia bacterial
Clinical narrative: Inpt:  11/13/2022-11/16/2022.  COVID+ 11/13/2022.  Vaccination status - pfizer x3 + moderna bivalent 11/13/22 H&P:  CHIEF COMPLAINT: Respiratory failure with hypoxia   Assessment & Plan Patient is a pleasant 59-year-old male with multiple sclerosis who presents with a 5 week history of cough and intermittent fevers.  Patient notes current symptoms have been present for least 2 weeks patient has persistent cough some sputum production fevers fatigue.  Patient presented emergency department for evaluation notes that he had tested positive for COVID on November 5th.  Patient noted to be hypoxic COVID positive question pneumonia on chest x-ray.  Patient will be admitted treated with nebulizers placed on Decadron given the length of his symptoms does not qualify for remdesivir.  Patient's procalcitonin is at 0.41 will empirically cover with community-acquired pneumonia coverage will check strep and Legionella antigen will also do a MRSA screen.   Pneumonia due to organism Assessment & Plan Procalcitonin level 0.41 as COVID positive does have infiltrate on chest x-ray will empirically covered for community-acquired pneumonia in addition to Decadron oxygen and bronchodilators for his COVID-19 will check antigens for Streptococcus Legionella and do a MRSA screen   MS (multiple sclerosis) Assessment & Plan Stable   * COVID-19 Assessment & Plan Notes patient had symptoms on and off for the last 5 weeks current symptoms started at least 2 weeks ago patient did test positive for COVID on November 5th.  Patient presents with acute hypoxic respiratory failure with infiltrate on chest x-ray procalcitonin at 0.41 positive COVID.  Patient admitted placed on Decadron will receive bronchodilators oxygen therapy is not a candidate for remdesivir given his symptoms for at least 2 weeks.  Will cover with empiric community-acquired pneumonia coverage given his procalcitonin level. 11/15/22 progress note:   Assessment/Plan  I spoke to patient's wife last night regarding patient's progress.  She would like to take him home ASAP, because "he hates hospitals."  I assured her that we would like to make him as comfortable as possible in order to get the right amount of treatment of his secondary bacterial pneumonia.   Nocturnal Nursing notes reviewed:  A&O, severe respiratory precautions maintained.  Tele NSR.  VSS.  Eager for discharge home.   Spoke w/ RN regarding hypoxia after ambulation.  Will check CXR and D dimer and BNP (especially w/ elevated liver enzymes and possibility of passive congestion.) ASSESSMENT / PLAN: Elevated transaminase level Assessment & Plan Secondary to viral illness BNP negative and CXR negative to suggest passive congestion from liver.   Hold hepatotoxins RUQ US if continues to worsen Asthma with COPD with exacerbation  Assessment & Plan Patient has bronchiolar breath sounds.   Will continue Azithromycin and Rocephin Will hold Decadron and use Solumedrol Will start Pulmicort neb x 1 followed by Symbicort 2 puffs BID today.   IS, Acapella Expectorants.   SC Briefly discussed tobacco cessation:  Patient declined nicotine patch or gum or anxiolytic for nicotine habit.   Respiratory failure with hypoxia  Assessment & Plan Patient now up to 3.5 L Acute respiratory failure with hypoxia  Assessment & Plan Patient's oxygen requirements decreased to 1 L with rest and  3.0 L after ambulation from BR   I/O net - 60 mL Secondary to CAP w/ COVID + and elevated procalcitonin, so treating for a secondary bacterial infection.   CXR shows resolved pneumonia BS suggestive of bronchitis BC x 2 remain negative to date D dimer and BNP negative Streptococcal and Legionella Urinary Ag's negative MRSA PCR negative COVID + 11/2 (vs 11/5) and + 11/13.   WBC improving, afebrile, improving CRP.  Negative D dimer.  Plan:  CPC w/ antibiotics, IS, Acapella, Expectorants Will add OTO of Pulmicort and add Symbicort for bronchitis.  Will change Decadron with Solumedrol ? ST eval for dysphagia with MS history.    Re-evaluate this afternoon.   I explained to patient that I didn't feel that he was ready to go home yet.  He handled this news graciously.   Pneumonia due to organism Assessment & Plan Unable to obtain sputum culture yet.   MRSA PCR negative Streptococcus and Legionella urinary antigen.   Procalcitonin elevated.  Repeat CXR today shows no infiltrate  Will treat more for bronchitis.   Consider CT thorax if worsens MS (multiple sclerosis)  Assessment & Plan Per history  Monitor for neurogenic bladder or dysphagia.   Continue home MS medications.   ST evaluation Bladder scan for PVR * COVID-19 Assessment & Plan Symptom onset: 5 weeks ago.   COVID + 11/5/22 Film array + for COVID 19 only Continue serial labs Continue MDI's, Expectorants, add Symbicort and change Decadron to Solumedrol.    GI and DVT prophylaxis BS stable on steroids.   Procalcitonin elevated, so will continue tx for secondary bacterial infection.   Try to get SC