Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Vomiting
Clinical narrative: COVID+ per reported home test 10/22/22.  Vaccination status - moderna x4. No d/c summary available to date Inpt. 11/2/22-11/13/22 H&P:  HISTORY OF PRESENT ILLNESS: Patient presents to the ED at the insistence of her son for 12 days of Covid symptoms.  Her symptoms started with fatigue on 10/21/2022.  She had been up North her husband, noticed that she was feeling very tired on the drive back home. On the 22nd, she had severe muscle aches, that same day she had a positive home COVID test.  Her husband also tested positive for COVID.  In fact he was hospitalized last week with symptoms.  She is unsure if she ever had a fever but she did report having episodes of sweating.  She continues to have a very persistent cough, sometimes productive of gray colored sputum.  She has used Tessalon Perles for this with no relief.  Additionally, she took the 5 day course of antivirals with no improvement of her symptoms.  No diarrhea. She has had some vomiting, but reports this was more dry heaves from not eating, nothing really came up. She reports that she has had a very poor appetite, she reports that she has had some confusion and has felt like her mind is foggy, like she does not know even how to make herself food. She did take her medications this morning but believes she may have missed some doses. When her son went to the house to check on her and her husband today, he insisted that she needed to come to hospital for evaluation.  She endorses shortness of breath, denies any chest pain.  Does report some back pain but feels it is from being on the emergency department stretcher.  She is thirsty at this time, she is hungry at this time.  Emergency department course - she was tachycardic with a rate into the 160s, electrocardiogram showed atrial fibrillation with RVR with a rate of 171. She was tachypneic with a respiratory rate up to the 30s.  Blood pressures were soft with systolics in the 90s, maps did maintain over 65. Her blood pressures were responsive to IV fluids and she received 2 L fluid bolus and was maintained on IV fluids with normal saline at 125 mL.  Blood cultures x2 were obtained.  CXR with findings concerning for pneumonia. She was started on Zithromax and Rocephin. She was given oral cardizem and IV cardizem with some improvement in heart rates although she still remained tachycardic with rates between 120 and 140 during the interview.  She will be admitted to the hospitalist service for community-acquired pneumonia and atrial fibrillation with RVR.  ASSESSMENT/PLAN:  Community Acquired Pneumonia - CXR read as new patchy bilateral airspace disease suspicious for pneumonia - on room air  - started on IV Rocephin and Zithromax in ED              -will continue on IV Rocephin and po Zithromax  - sputum cultures if able to obtain - strep pneumo and legionella urine antigens  - incentive spirometry and acapella - PT and OT evaluations  - am labs  Atrial Fibrillation with RVR - rates 171 on ECG  - given 30mg oral Cardizem and 10 mg of IV Cardizem in ED; will order prn Cardizem for HR >140 with close monitoring of blood pressures. May need CCU transfer if persistently  tachycardic.  - on tele  - cont home dose Toprol XL 50mg qam and 25mg qpm  - cont home dose Eliquis 5mg BID - follows with Cardiology   Sepsis secondary to Pneumonia - pt meets sepsis criteria for tachycardia and tachypnea   - source is bilateral PNA - received 2L fluid in ED, on maintenance fluids - started on antibiotic therapy with Zithromax and Rocephin  - lactic acid 1.5, repeat 1.2  - blood cultures X 2 drawn in ED, will follow  - sepsis reassessment completed  Subacute Covid Infection  - home test positive 10/22 - received  molnupiravir 10/24-10/28 - add ddimer  - supportive care, antitussives prn   HTN - BP are soft but responsive to fluids, continue BB for rate control   Depression with Anxiety - cont home dose Celexa 10mg daily and Buspar 10mg BID   Follicular lymphoma grade II of intrapelvic lymph nodes - 2016  - has port a cath  - s/p radiation  - not currently on chemo therapeutics, last infusion in April 2022 - follows with Dr   Lymphedema of Left LE - noted, of the left thigh  - wears compression stockings  Alopecia - noted   Code status:  VTE prophylaxis: Eliquis   11/12/22 Progress note: Progress Note. HOSPITALIST  Chief complaint Shortness of breath  Assessment/Problem List Patient is a 77 y.o. female with PMHx of follicular lymphoma s/p chemotherapy (last treatment early 2022), A-fib, HTN, Depression with anxiety, who presented with sepsis secondary to CAP after a COVID-19 infection. Patient still hypoxic.  Rates are much more controlled today. Now attempting to wean from supplemental oxygen.  Plan  Community Acquired Pneumonia Acute hypoxic respiratory failure Sepsis - present on admission - IV Rocephin and Zithromax got 3 days, then switched to levaquin - Levaquin on 11/5 - 11/12 - Unasyn started 11/12 -  O2 today still on 2-3L - IV lasix given x1 on 11/5, repeated on 11/6 - sputum culture pending, NGTD - strep pneumo and legionella negative - blood cultures NGTD  - incentive spirometry and acapella - wean O2 as able - daily CRP, was very elevated,  - CT with evidence of continued pneumonia in the LLL with additional    Paroxysmal Atrial Fibrillation with  RVR- Now rate controlled - per cardiology: adding digoxin on 11/5, continue  - increasing toprol to 75mg BID - Cardizem held - cont home dose Eliquis 5mg BID - follows with Cardiology -ECHO 11/7 - LVEF 57%  Subacute Covid Infection  - home test positive 10/22 - received  molnupiravir 10/24-10/28 - ddimer wnl - supportive care, antitussives prn   Reactive Airway Disease- not wheezing - Symbicort subbed for home Breo Ellipta - use xopenex instead of albuterol given HR  HTN - continue BB for rate control   Depression with Anxiety - cont home dose Celexa 10mg daily and Buspar 10mg BID   Follicular lymphoma grade II of intrapelvic lymph nodes - 2016  - chronic lymphopenia - has port a cath  - s/p radiation  - not currently on chemo therapeutics, last infusion in April 2022 - follows with Dr    Lymphedema of Left LE - noted, of the left thigh  - wears compression stockings Alopecia - noted   VTE prophylaxis: Eliquis   Dispo: Pt. Will likely need 24 hours while weaning from supplemental oxygen.  May need to discharge with supplemental oxygen