Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: COVID-19 pneumonia, Cerebral infarction, Cerebral small vessel ischaemic disease, Chest X-ray abnormal, Computerised tomogram head normal
Clinical narrative: Hospitalized (11.1.21 - still hospitalized / admitted);  COVID-19 positive (10.31.21);  fully vaccinated  CHIEF COMPLAINT:  Acute respiratory failure due to COVID-19 (HCC) Plan: Presents in respiratory failure with (+) Covid. Also with dysphagia/diplopia and right hand ataxia/right facial numbness x3-4 days. Persistent cough productive of profuse mucus. Unable to swallow. CT head/CTA head/CT perfusion negative. CXR with new right sided consolidation since yesterday. Treat Covid, treat aspiration pneumonia, check Echo/MRI, await Telestroke and SLP input. Rectal aspirin.  HISTORY OF PRESENT ILLNESS: Patient is a 56 y.o. female who presents today with 5 days of fatigue, shortness of breath, cough, and 4 days of difficulty swallowing, double vision, right arm weakness, right facial numbness. She tested (+) for Covid and tried outpatient tx, returns for persistent s/s. PMH of asthma, thoracic meningioma, hypertension, GERD.  In the ED, where she presented late afternoon, she was initially difficult to get hx from, but it was gathered that she had stroke s/s since at least this morning. CT head/CTA head, CT perfusion negative. Strep culture checked, NGTD. CXR showed a new right sided consolidation from yesterday. Troponin negative, labs showed leukocytosis 19.7 which could be related to decadron started yesterday. She requires admission for management of acute respiratory failure d/t Covid pneumonia with likely aspiration pneumonia, as well as evaluation of likely bulbar stroke.  At time of my exam, she is sitting up on gurney. Mildly tachypneic on room air but not in distress. However, she goes into coughing paroxysms every 1-2 minutes, producing profuse thin yellow sputum, and her speech is hoarse and sounds rhonchorous. She is blinking left eye a lot, explains it is to help her eyes focus, which is a new issue since this weekend.  She feels numb on her right face. She can't move her right hand as well as usual. When she tries to swallow even water or applesauce, she feels it gets stuck on the way down, and points to her mid chest. She's not been peeing much, as she hasn't been able to eat or drink hardly at all x4 days. She has no chest pain, rash, joint pains. She works as a patient advocate for an inpatient psychiatric facility.    Acute ischemic stroke (Right medullar ischemic stroke); etiology to be determined: small vessel disease vs COVID-induced possible hypercoag state vs cardiogenic vs others.  Progress Note from 11.5.21:  11/05/2021 will hold off on feeding her today may need to do peripheral hyperalimentation.  Her chest x-ray looks much worse up concerned that she may be continuing aspirate.  She has been on antibiotics we did change her antibiotics.   11/05/2021 despite having a good gag reflex the she does appear to be aspirating.  I have make her NPO for now.  Consider oral hyperalimentation verses peripheral.  11/05/2021 of chest x-rays worse.  She is requiring more oxygen.  She had dramatic changes over the evening in last night.  I have ask for an ID consult.  I changed her to Zosyn and vancomycin.  11/05/2021 she is had dramatic increase in her oxygen demand overnight.  Presently on high-flow oxygen.  Chest x-ray revealed increasing infiltrates bilaterally specifically on the right radiology's interpretation is consistent with COVID superimposed with aspiration.  I am concerned that may be also fluid overload.  Check proBNP and echocardiogram also give her dose of Lasix.  She is in a prone position now.