Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Differential white blood cell count abnormal, Dilatation atrial, Diuretic therapy, Drug intolerance, Dyspnoea
Clinical narrative: Hospitalized (1.1.22 - still admitted currently); COVID-19 positive (12.31.21); Fully vaccinated  - pfizer x2 H&P: CHIEF COMPLAINT: Acute respiratory insufficiency     Assessment/Plan    ASSESSMENT / PLAN: # Acute on Chronic Respiratory Insufficiency with COVID-19 -CXR personally reviewed and noted very mild opacity at right lung base with cardiac enlargement -completed vaccination series for COVID-19 (3/2021) but no booster -CXR personally reviewed and noted cardiac enlargement with faint opacity in right lower lobe              -Decadron (6 mg PO daily), trend CRP, continuous pulse oximetry for now              -check pro-calcitonin in AM (in hopes renal function improved) and if elevated start Abx              -VTE prophylaxis with Eliquis (resume if Hgb stable in AM)  # History of Cryptogenic Organizing PNA # History of Tobacco Us -quit tobacco in 1997 and diagnosed with COP (8/2020) and evaluated by pulmonary at that time -continue home albuterol and Spiriva    # Acute on Chronic Kidney Disease Stage 3b -baseline creatinine 1.4-1.6 and increased to 1.8 last month -treated with 1 liter bolus of NS in the ED and suspect pre-renal from diuresis & possible diarrhea              -IVF (NS 75 cc/hr) and monitor respiratory status closely given CHF history              -daily renal panel, avoid nephrotoxins and dose medications renally   # Hypokalemia -potassium 2.9 noted on admission and treated with 20 mEq IV and 20 mEq PO KCl by ED -suspected secondary to diarrhea and diuretic use and recheck potassium along with Mg in AM   # Chronic Diastolic Heart Failure -patient unsure of how much Lasix he actually takes and reports dry weight to be around 212 lbs/96kg -Echo (10/2021) with preserved LVEF, mild aortic root dilation and mild bilateral atrial dilation              -standing daily weight (97.2kg today), I/O, fluid restriction to 2 liters              -holding lasix given AKI and hypokalemia, daily renal panel   # Permanent Atrial Fibrillation # Prolonged QTC -diagnosed 3/2020 with DCCV (2/2020) and EKG on presentation with QTc >500 ms -CHA2DS2-VASc score of at least 3 (CHF, HTN, age) -evaluated by cards (12/2/21) and plan for rate control only due to intolerance to Amiodarone -telephone notes report that Amiodarone was started (12/9)              -hold Amiodarone given prolonged QT and if rate controlled would not restart               -rate control: Metoprolol succinate (50 mg BID) and Diltiazem (360 mg daily)              -anticoagulation: Eliquis (5 mg BID) resume in AM if hematoglobin stable   # Essential HTN -holding home Lasix given AKI and hypokalemia, also holding Lisinopril  -continue Metoprolol succinate (50 mg BID) and Diltiazem (360 mg daily)   # Acute Anemia -baseline Hgb 13-14 and presented with a Hgb of 9.5 -noted to be on Eliquis for atrial fibrillation and hold for now (resume in AM if Hgb stable)   # Hypothyroidism -TSH 99.3 with free T4 0.2 (10/8/21) -Levothyroxine (50 mcg daily)   # HLD  -Crestor (20 mg daily)   # Depression -holding Effexor given prolonged QT   Telemetry: prolonged QT VTE prophylaxis: Eliquis (restart 1/2/21 if Hgb stable) Nutrition: general diet (2 liter fluid restriction) Code Status: full code         Subjective    HISTORY OF PRESENT ILLNESS: Patient is a 73 y.o. male who presented to ED with complaints of fatigue, cough and dyspnea. Reported to the ED he has had these symptoms for the past year but worsened over the last 2 days. He presented to UC on 12/31 for the previous stated symptoms including fever and diarrhea. At the time he tested positive for COVID-19 and per ED note family requested patient present to ED tonight.    Patient is somewhat of a poor historian. He initially states dyspnea occurred today before being informed of UC presentation and then states dyspnea started the day he went to UC. He states dyspnea assocaited with productive cough and "low grade fevers". He denies diarrhea (although reported by UC) and states he has a good appetite. Patient states he lives alone and does take lasix daily, but unsure of how much he takes. He tells me his typical weight is 212 lbs and reports he checks his weights daily. He quit tobacco in 1997 and states no used alcohol in last year since he is on Eliquis.      Patient Active Problem List Diagnosis ? Left basilar pulmonary infiltrate ? Acute exacerbation of CHF (congestive heart failure) (HCC) ? Acute respiratory failure with hypoxia (HCC) ? Atrial fibrillation and flutter (HCC) ? Dyspnea ? Acute respiratory failure (HCC) ? Cryptogenic organizing pneumonia (HCC) ? History of tobacco abuse ? Postprocedural pneumothorax ? Pleural effusion, left ? Cardiomyopathy (HCC) ? Acute diastolic (congestive) heart failure (HCC) ? Hypokalemia ? COVID-19 ? Acute renal failure superimposed on stage 3b chronic kidney disease (HCC) ? Acute renal failure superimposed on stage 3b chronic kidney disease, unspecified acute renal failure type (HCC) ? Acute respiratory insufficiency Review of Systems Constitutional:  Positive for fever. Negative for appetite change and chills.  HENT: Negative for congestion and rhinorrhea.  Respiratory:  Positive for cough and shortness of breath.   Cardiovascular:  Positive for leg swelling. Negative for chest pain, palpitations and orthopnea.  Gastrointestinal:  Positive for vomiting (non-bloody). Negative for nausea, abdominal pain, constipation, diarrhea and blood in stool.  Genitourinary:  Negative for difficulty urinating, dysuria and hematuria.  Musculoskeletal:  Positive for falls (slipped on ice 5 days ago, no head trauma).  Neurological:  Negative for headaches, dizziness and light-headedness.  Psychiatric/Behavioral:  Negative for anxiety and sleep disturbance.  Skin:  Negative for rash and wound.          Objective    OBJECTIVE: BP 121/68  | Pulse 64  | Temp 36.7 °C (Oral)  | Resp 18  | Ht 1.702 m  | Wt 97.2 kg  | SpO2 100%  | BMI 33.56 kg/m²    Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is obese. He is not ill-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General: No scleral icterus. Cardiovascular:     Rate and Rhythm: Normal rate. Rhythm irregular.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No wheezing, rhonchi or rales.  Abdominal:     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.     Comments: Somewhat firm  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: He is alert.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.   1/11/22 General Medicine Progress Note: Attestation signed by MD at 1/11/2022  6:00 PM I have personally interviewed and examined the patient on 1/11/2022. Management was discussed with the provider below. I agree with the documented findings and plan of care in his/her note.   Brief exam: alert, oriented sat SpO2: 95 % O2 Flow Rate (l/min): 5 l/min no accessory mm use and appears comfortable, sinus, cta, no peripheral edema, pleasant   Brief history and medical decision making: 73yo recovering from covid pna on IV steroids. Wean to po steroids in next 24-48 hours. Currently on solumedrol bid-- > solumedrol daily then prednisone taper.   Expected Discharge date: Jan 13, 2022      Expand All Collapse All     Hide copied text  Hover for details  Progress Note    CHIEF COMPLAINT: Acute respiratory insufficiency     Assessment/Plan     ASSESSMENT / PLAN: Principal Problem:   Acute respiratory insufficiency Active Problems:   COVID-19   Acute renal failure superimposed on stage 3b chronic kidney disease (HCC)   Acute renal failure superimposed on stage 3b chronic kidney disease, unspecified acute renal failure type (HCC)   COVID 19 PNA Acute Hypoxic Respiratory Failure secondary to above-stable Symptom onset 12/30, positive test 12/31 at urgent care. Vaccinated, but did not receive booster. - CXR 1/4: progressing mixed interstitial and airspace opacities  - Remdesivir completed 1/3-1/7 - Repeat CXR 1/9 with interval improvement - Will start weaning steroids now that back on NC. Decreasing to salumdrol 50mg IV daily  - Lasix changed back to home dose 60mg PO daily - Continuous pulse ox, IS, prone as tolerated  - Checking US bilateral LE due to L>R lower extremity edema   New Anemia,stable - Baseline Hgb 13-14 - hgb now stable in 9s  - Denies hematemesis, hematochezia, melena. No EGD or colonoscopy in our system->would likely benefit from outpt eval   - Ferritin 1,292, IBC 229, Fe 38, Fe sat WNL; B12/folate WNL  - PPI   Leukocytosis; improving - likely reactive to steroid - monitor off abx    Transaminitis, improving - likey secondary to COVID - continue to trend   History of Cryptogenic Organizing PNA History of Tobacco Use - Quit tobacco in 1997 and diagnosed with COP (8/2020) and evaluated by pulmonary at that time - Continue home albuterol and Spiriva    AKI on Chronic Kidney Disease-resolved - creatinine now back to baseline (1.4-1.6) - Trend - avoid nephrotoxins and renally dose medications   Chronic Diastolic Heart Failure - Echo (10/2021) with preserved LVEF, mild aortic root dilation and mild bilateral atrial dilation - Lasix as above - daily weights, strict I&Os - 2 gm Na and 2 L fluid restriction    Permanent Atrial Fibrillation Prolonged QTC ,resolved  Diagnosed 3/2020 with DCCV (2/2020) and EKG on presentation with QTc >500 ms.  CHA2DS2-VASc score of at least 3 (CHF, HTN, age). Evaluated by cards (12/2/21) and plan for rate control only due to intolerance to Amiodarone - repeat EKG: afib nonspecific t wave abnormalities; qtc 443  - amio originally held due to prolonged QTc, now normalized, will continue to hold for now as pt HR remains stable  - rate control: Metoprolol succinate (50 mg BID) and Diltiazem (360 mg daily) - anticoagulation: Eliquis (5 mg BID)     Essential HTN, stable - continue lasix, lisinopril, metoprolol succinate, diltiazem    Hypothyroidism - TSH 99.3 with free T4 0.2 (10/8/21). TSH now 8.85 - Continue Levothyroxine (50 mcg daily)   Steroid induced hyperglycemia - A1c 6.2 - glucose levels improved on lantus 6u with low dose corrective, continue   Hyperlipidemia - continue statin   Depression - continue effexor     DVT prophylaxis: On eliquis   Code status Full code   Dispo: Weaned to 6L O2, continue to wean as able. Starting to taper IV steroids. Lasix transitioned back to PO. Likely ready for discharge once stable on 3-4L and not requringin more than 6L O2 with ambulation.   The above stated assessment and plan was discussed with Dr. and reflect her input.     SUBJECTIVE: Patient reports breathing feels well but he feels more foggy than prior. Denies any chest pain, SOB, n/v/d or abdominal pain. When asked about LE edema endorses that his left is normally more swollen than right but does not know why and has not had any prior US for it.    Review of Systems Constitutional:  Negative for chills and fever.  Respiratory:  Positive for cough. Negative for shortness of breath.   Cardiovascular:  Negative for chest pain.  Gastrointestinal:  Positive for constipation. Negative for nausea and abdominal pain.  Musculoskeletal:  Positive for edema.  Neurological:  Negative for dizziness.          Objective     OBJECTIVE: BP 128/86  | Pulse 72  | Temp 36.4 °C (Oral)  | Resp 16  | Ht 1.702 m  | Wt 93.7 kg  | SpO2 97%  | BMI 32.35 kg/m²  FIO2 (%): 50 % Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is not toxic-appearing.  HENT:     Head: Normocephalic and atraumatic.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Trachea: No tracheal deviation.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.     Comments: Crackles at bilateral lung bases Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.     Right lower leg: No edema.     Left lower leg: Edema (trace pitting) present.  Skin:    General: Skin is warm and dry.     Findings: No erythema.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.