Age: 51.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Fibrin D dimer increased, Hypoxia, Immunoglobulin therapy, Influenza like illness, Laboratory test abnormal
Clinical narrative: Patient with 2 COVID vaccinations, last dose 06/14/21, who admitted with COVID complications.  Provider discharge note below:  "52 YO male who presented to the hospital for evaluation of worsening dyspnea.  The patient states that he started up approximately 2 weeks ago with a scratchy throat and a cough productive of clear sputum and subsequently tested positive for COVID 19 and was doing good for a whole week.  He was also having a some fevers and chills which he took some Tylenol over the counter and his PCP prescribed him something for the cough which helped some.  A 2nd week of his infection, he started training for the worse with development of generalized body aches, chest congestion and pressure and increasing cough and subsequently over the week and became more short of breath with worsening overnight.  This prompted his visit to the emergency room today.  He denies any pleuritic chest pain and he denies any change in the color of his sputum.  He denies any hemoptysis. He had diarrhea once last night and once this morning.  Otherwise, no nausea, vomiting or abdominal pain.  His appetite is decreased.  He does not have any loss of the med he can add the the food very well and in fact, might have lost between 5-7 lb in the last 2 weeks.   He is not a smoker and has had no history of any lung issues.  He sees Dr. for his CLL and is currently not on any formal treatment but he is monitored very closely.  He gets blood work every 3 months   In the emergency room, he had a CT of the chest with findings consistent with some ground-glass opacities and consolidation and possible pneumonia.  Labs reviewed he does have leukocytosis although he could have a leukocytosis from his CLL but is significantly lower compared to his last couple laboratory results.  He also has significant elevation of D-dimer which will need to follow very closely.  Upon arrival, he has a very high fever but he denies having any dysuria, frequency urgency or any other indications of infection except for having known to have COVID 19 and now with findings of possible PNA onn the CT scan. (HPI per Dr)   Hospital Course: No notes on file Patient is a 52yr old male with a history of CLL, OSA on CPAP who prsented with worsening SOB, cough and hypoxia. He was diagnosed with covid 2 weeks ago and had some mild flu-like symptoms but last night symptoms got worse with fever, worsening cough and hypoxia. He feels a bit better this morning though seems to have desaturated with minimal exertion.   Acute Hypoxic Respiratory failure secondary to COVID PNA - Improving clinically on steroids day#4, not a candidate for remdesivir as symptoms started 2 weeks ago. He remains afebrile though still has some leukocytosis - in setting of CLL. On antibiotics (ceftriaxone and doxycycline) day#4 for possible superimposed bacterial infection and received IVIG 400mg/kg following discussion with hemonc. Today he feels better, DOE is improving and ready to go home on 2.5L NC oxygen.   CLL - His BMB from 1/5/18 was positive for CLL, 13 q deletion which is a good prognostic sign so chemotherapy or TKI therapy not recommended at this time. Follows with  Dr.   Discharge Exam: General - Adult male, not in obvious distress HEENT - NC AT Heart - S1 S2 RRR Lung - Moderate air entry with scant rales Ext - No LE edema Neuro - AAO x3   Issues Requiring Follow Up: (Who, what, when, and how communicated?) He is to follow up with PCP."